II.INTRODUCTION:

The term Emergency Management traditionally refers to care given to patients with urgent and critical needs. Large numbers of people seek emergency care for serious life-threatening cardiac conditions, such as myocardial infarction, acute heart failure, pulmonary edema, and cardiac dysrhythmias.

The need for professional nurses to be prepared in emergency and disaster nursing becomes more evident as the complexity of our lives increases owing to the discovering of new scientific knowledge and its application to the everyday world.

Because nurses represent the largest group of trained professional health worker available, their awareness of and preparation for emergency care of the ill and injured are essential.

III.DEFINITION OF TERMS:

Antivenin- antitoxin manufactured from venom of poisonous snakes to

assist the patients immune system to response to an

envenomation.

Carboxyhemoglobin- hemoglobin that is bound to carbon monoxide

and therefore is unable to bind with oxygen, resulting in

hypoxemia

Corrosive poison- alkaline or acidic agent causes tissue destruction

after contact.

Cricothyroidotomy- surgical opening of the cricothyroid membrane to

obtain an airway that is maintained with a tracheostomy

or endotracheal tube. Diagnostic peritoneal Lavage- instillation of lactated ringers or normal

saline solution into the abdominal cavity to detect red

blood cells, bile, bacteria, amylase, or gastro-intestinal

contents indicative of abdominal injury. Emergent- triage category signifying life-threatening injuries or illnesses

requiring immediate treatment.

Evenomation- injection of a poisomous material by using string, bite, or

other means.

Fasciotomy- surgical incision of the extremities to the level of the fascia

to relieve pressure and restore neurovascular function to

the extremity.

Hare Traction- portable in-line traction applied to the lower extremity to

manage femur or hip fractures or dislocations.

Non urgent - triage category signifying episode or minor injury or illness

in which treatment may be delayed several hours or longer

without increased morbidity.

Shock loss of effective circulating blood volume resulting in end-organ

ischemia and cellular metabolic derangement Triage- process of assessing patients to determine management priority

Urgent- triage category signifying serious illness or injury that is not

immediately life- threatening.

IV.SCOPE AND PRACTICES OF EMERGENCY NURSING CARE

The emergency nurse has had specialized education, training, and experience to gain expertise in assessing and identifying patients health care problems in crisis situations.

Nursing interventions are accomplished interdependently, in consultation with or under the direction of a licensed physician or nurse practitioner. The strengths of nursing and medicine are complementary in an emergency situation.

Appropriate nursing and medical interventions are anticipated based on assessment data.

During the mid 1960s. The need for specialization of emergency cervices was identified as a national priority in order to reduce the associated morbidity and mortality resulting from catastrophic illness or injury. The scope of the services ranges from treatment of acute conditions that threatens the lost of life, limb or vision to management of non- urgent, chronic conditions.

V. ISSUE ON EMERGENCY DEPARTMENT UNITS

This issue includes legal issues, occupational health, and safety risk for emergency department (ED) staff, and the challenge of providing holistic care in the context of fast-paced, technology-driven environment in which serious illness and death are confronted on a daily basis. Emergency nursing was officially recognized as specialty in 1970. The National Association representing this nurse is the (ENA) Emergency Nursing Association.

Definition of Emergency Nursing involves

Assessment ,

Diagnosis and treatment of perceived actual or potential, sudden or urgent, physical or psychosocial problem that are primary episodic or acute these may require minimal care of life support measure

Education of patient and significant others

Appropriate referral

Knowledge of legal implications.

Nurses employed in an ED must be prepared to provide care to client of all age group who may have any possible illness or injury.

It often cited that emergency nurse must have an understanding of almost all disease process specific to any age group.

Legal Issues Nurses deal with a variety of legal issues in whatever specialty area they practice Federal Legislation Mandated

Any client who presents to an ED seeking treatment must be rendered aid regardless of financial ability to pay for services.

Requiring ED personnel to stabilize any client considered medically unstable before transfer to another health care facility. This stabilization must occur regardless of the client financial ability to pay for services.

a. FACTS ABOUT EMERGENCY DEPARTMENT UNITS

People age 75 years and older had the highest rate of ED visits. The national average is 39 visits per 100 persons per year.

Stomach and abdominal pain, chest pain, and fever, were the most commonly recorded reasons for a visit in the ED.

Ages 15-24 years had the highest injury visit rate.

About 12% of patients seen in the ED were admitted to the hospital

b. DOCUMENTATION OF CONSENT

Patient must consent to invasive procedures unless unconscious or in critical condition.

If unconscious and without family or friends, this fact should be documented.

After treatment, notations are made on the record about the patients condition on discharge or transfer and about instructions given to the patient and family for follow-up care.

c. LIMITING EXPOSURE TO HEALTH RISK

Health care providers are at increased risk for exposure to communicable diseases through blood or other body fluids. This risk is further compounded in the ED because of the common use of invasive treatments. All emergency health care providers should adhere strictly to standard precautions for minimizing exposure.

d. PROVIDING HOLISTIC CARE

Sudden illness or trauma is a stress to physiologic and psychological homeostasis that requires physiological and psychological healing.

Patients and families experience real and terrifying fear of death, mutilation, immobilization, and other assaults on their personal identity and body integrity.

Assessment of the patient and familys psychological function includes evaluating emotional expression, degree of anxiety, and cognitive functioning.

d.1 Patient focused interventions

a. Those caring for the patient should act confidently and competently to relieve anxiety.

b. Reacting in a warm manner promotes a sense of security.

c. Unconscious patient should be treated conscious

d.2 Family-focused interventions

a. Family is kept informed about where the patient is, how he or she is doing, and the care that is being given.

b. Anxiety and denial (Family members are encouraged to recognize and talk about their feelings of anxiety. Asking questions is encouraged.)

c. Remorse and guilt (Expressions of remorse and guilt may be heard, with family members accusing themselves of negligence or minor omissions. They are urged to verbalize feelings.

d. Anger (Allow the anger to be ventilated, assist the family to identify their feelings or frustrations)

e. Grief (Help family members to work through their grief and support their coping mechanisms.)

VI. PRINCIPLES OF EMERGENCY NURSING CARE

Principles of Assessment and Emergency Management

1. Treat the potentially life threatening first.

GOAL : a. Preserve life

b. Prevent deterioration before definitive treatment

can be given

c. Restore patient to useful living

2. Stabilize the pulmonary cardiovascular and central nervous system

a. Maintain a patent airway and provide adequate ventilation. Employing resuscitation measures when necessary.

b. Control hemorrhage and its consequences

c. Evaluate and restore cardiac output

d. Prevent and treat shock; maintain or restore effective circulation.

e. Carry out rapid initial and ongoing physical examinations. (The clinical course of the injured or seriously ill patient is not static).

f. Assess whether or not the patient can follow command. Evaluate the size and reactivity of the pupils and motor responses.

g. Splint suspected fractures

h. Protect wound with sterile dressings

i. Check to see if patient has a medic alert or similar identification designating allergies etc.

j. Start a flow sheet of the patient vital signs BP, PR, RR to guide decision makingTRIAGE

The word triage comes from the French word trier, meaning to sort. In the ED, triage is used to sort patients into groups based on the severity of their health problems and the immediacy of with which these problems must be treated.

PURPOSE:

To expendiently determine the severity of the clients problem or condition

2 SYSTEM OF TRIAGE

1. ED Triage

2. Field Triage

Three categories of ED TRIAGE

a. Emergent- has the highest priority, conditions are life threatening, and they must be seen immediately.

b. Urgent- has serious health problems, but not immediately life threatening ones: they must be seen within 1 hour.

c. Non- urgent- has episodic illness that can be addressed within 24 hours without any increasing morbidity.

2 DIVISION OF NURSING ASSESSMENT PROCESS IN ED

1. Primary Assessment

Its purpose is to identify any client problem that poses a threat immediate or potential to life, limb or vision. If any abnormalities are found immediate intervention such as CPR and advance life support (ALS) must be instituted to aid in preserving clients life.

2. Secondary Assessement

Is performed to identify any other non life threatening problems that client may be experiencing.

Element includes Secondary Assessment

1. Neurologic assessment determine clients

A. Level of consciousness

1. Alert respond fully and appropriately to stimuli

2. Lethargic- drowsy, respond to question then fall asleep.

3. Obtunted open eyes, responds slowly, confused

4. Stuporous Arouses from sleep only after painful stimuli.

5. Comatose unarousable with eyes closed

B. Orientation to person, place, time and event

C. Glasgow Coma Scale (GCS) score

D. Pupillary size, equality and reaction to light and accommodation.

E. Motor movement and strength of hand grips and pedal pushes

2. History

3. Pain asking questions according to mnemonic PQRST often provide useful information.

P Provokes are there any specific cause the pain to

increase or decrease

Q Quality - what descriptive terminology identifies the pain

R - Region/ radiation where is the pain located and does it

moves to the other side

S Severity use rating scale from 1- 10

T- Timing How long has the pain has been present

Are there cycle related to when the pain is present or absent

4. General overview Note the client overall condition skin color, gait, posture, unusual skin markings, body odor, vital signs.

5. Head to toe or focused assessment IPPA to determine additional normal or abnormal findings.

FIELD TRIAGE

Used during disaster. When health care providers are face with a large number of casualties, the fundamental principle guiding resource allocation is To do the greatest good for the greatest number of people.. Decisions are based on the likelihood of survival and consumption of available resources.

The North Atlantic Treaty Organization (NATO) triage system is the widely use. It consist of 4 colors and signifies different level of priority.

Triage Categories

Color

Priority

Typical Condition

Immediate Injuries are life threatening but survivable with minimal intervention.

Individual in this group can progress rapidly to expectant is treatment is delayed

Delayed

Injuries are significant and require medical care but can wait hours without threat to life.

Minimal

-Injuries are minor and treatment can be delayed hours to days

Expectant

-Injuries are extensive chances of survival are unlikely even with definitive care.

-Comfort measure should be given

Red

Yellow

Green

Black

1

2

3

4

Sucking chest wound,Pneumothorax,

Incomplete amputation, unstable abdominal wound.

Stable abdominal wound without evidence hemorrhage, fracture requiring open reduction, debridment and external fixation

Minor burns, sprains, small lacerations without bleeding, upper extremity fixation, psychological disturbance.

Unresponsive patient, profound shock, agonal respiration, fixed dilated pupils, negative pulse and BP.

ASSESS AND INTERVENE

A systematic approach to effectively establishing and treating health priorities is the primary survey or the primary survey focuses on stabilizing life-threatening conditions. The ED staff work collaboratively and follow the ABCD (Airway, Breathing, Circulation, and Deformities) method.

ESTABLISH PATENT AIRWAY

Provide adequate ventilation, employing resuscitation measures when necessary. (Trauma patients must have the cervical spine protected and chest injuries assessed first.)

Evaluate and restore cardiac output by controlling hemorrhage, preventing and treating shock, and maintaining or resorting effective circulation.

Determine neurologic disability by assessing neurologic function using the Glasgow Coma Scale.

After these priorities have been addressed, the ED team will proceeds with the secondary survey. This includes:

Complete health history and head-to-toe assessment

Diagnostic and laboratory testing

Insertion or application of monitoring devices electrocardiogram (ECG) electrodes, arterial lines, or urinary catheters.

Splinting of suspected fractures

Cleaning and dressing of wounds

Performance of other necessary interventions based on the individual patients condition.

Once the patient is has been assessed, stabilized, and tested, appropriate medical and nursing diagnosis are formulated, initial important treatment is started, and plans for the proper disposition of the patients are made.

VII.CARE OF DIFFERENT MEDICAL EMERGENCY

a. AIRWAY OBSTRUCTIONAssessment

Asphyxia occurs for various reasons:

Inadequate oxygen in environment (e.g. smoke, toxic gases)obstruction of air passages (e.g. foreign bodies in airway, tongue falling back in pharynx, edema of respiratory tissue, laryngospasm)

Secretions in air passages (e.g. near-drowning, pulmonary edema)

Interferences with respirations (e.g. chest trauma, depression of respiratory center [drugs])

Interference with circulation (e.g. electric shock, MI, carbon monoxide poisoning)

Sign and symptoms include the following:

Dyspnea and restlessnessuse of accessory respiratory muscles (prominent neck muscles, intercostals ribs retraction; nasal flaring)

Wheezing or stridor from air moving through narrowed passageways

Sucking noise in inspiration if an open wound is present

Coarse rales (crackles) if fluid is present in alveoli

Pale skin (ashen on blacks)

Cyanosis (late sign)

Interventions:

1. Position the person to ensure a maximal airway.

2. If the airway is obstructed by a foreign body the person may need assistance in its removal.

A. FINGER SWEEP

Open the adults mouth by grasping both the tongue and lower jaw between the thumb and fingers and lifting the mandible (tongue-jaw lift)

B. THE HEIMLICH MANEUVER (SUBDIAGPHRAGMATIC ABDOMINAL THRUST)

Steps in doing Heimlich Abdominal Thrust Maneuver

For standing or Sitting Conscious patient:

Stand behind the patient, wrap your arms around the patients waist, and proceed as follows:

Make a fist with one hand, placing the thumb side of the fist against the patients abdomen, in the midline slightly above the umbilicus and well below the xiphoid process grasp the fist with the other hand.

Press your fist into the patients abdomen with a quick inward and upward thrust. Each new thrust should be a separate and distinct maneuver.

For patient lying down (unconscious):

Position patient on the back.

Kneel astride the patients thighs, facing the head.

Place the heel of one hand against the patients abdomen, in the midline slightly above the umbilicus and well below the tip of the xiphoid; place the second hand on top of the first.

Press into the abdomen with a quick upward thrust.

C. CHEST THRUST

For conscious patient standing or sitting (used for patient in advanced stages of pregnancy or in the marked obese patient

Stand behind the patient with your arms under the axillae to encircle the patients chest.

Place the thumb side of your fist on the middle of the patients sternum, taking care to avoid the xiphoid process and the margin of the rib cage

Grasp your fist with the other hand and perform backward thrusts until the foreign body is expelled or the patient becomes unconscious. Each thrust should be administered with the intent of relieving the obstruction.

For unconscious patient (lying position)

1. Place the patient on the back and kneel close to the side of the patients body.

2. Place the heel of your hand on the lower half of the sternum.

3. Deliver each thrust slowly and distinctly with the intent or relieving the obstruction.

D. JAW THRUST

Place hand on each side of the jaw, the angles of the patients lower jaw are grasp and lifted, displacing the mandible forward

3.Initiate artificial ventilations

Choking is airway obstruction caused by a foreign body that enters the

Airway.

Assessment

1. Victim is grabbing the throat with one or both and look panicky

2. Determine whether the victims airway is completely blocked

3. If the victim is able to speak, breath or cough with good air exchange, do nothing

4. If the victim is unable to speak , breath or cough with good air exchange, quick action is necessary to prevent suffocation.

Nursing Diagnoses

Ineffective airway clearance related to inability to expel an aspirated foreign object

Risk for suffocation related to aspirated foreign object

Goal and Outcome Criteria

Patent airway with normal respiration: Expulsion of foreign object, audible respirations, improving skin color, decrease coughing, reduce anxiety, normal pulse.

B.CARDIOPULMONARY ARREST

Cardiac arrest when the heart stops beating.

Pulmonary/ Respiratory arrest when respirations cease.

Cardiopulmonary arrest is the absence of a heart beat and

respirations and signifies a state of clinical death.

The cardiac and respiratory systems are so dependent on each other that when one fails the others quickly fail as well.

Nerve tissue is so susceptible to hypoxia (slow level of oxygen) that in most circumstances the brain cells begin to die after 4 minutes without oxygen or biologic death occurs.

Permanent brain damage - occur if circulation and oxygenation are not restored quickly after cardiopulmonary arrest.

Characteristics of Biologic death

Unresponsiveness

Cessation of respirations

Development of pallor and cyanosis

Absence of heart sounds and Blood pressure

Loss of palpable pulse

Dilations of the pupils (Pupillary response can be misleading in patient who are receiving drugs such as atropine of opium derivatives or in the presence of corneal pathologic conditions)

Ventricular fibrillation or ventricular asystole will appear (if hospitalized patient is being monitored by means of ECG machine or cardiac monitor).

Basic life support is the immediate care given to maintain

Oxygenation of the brain until advance medical support is

Available.

CPR (Cardio Pulmonary Resuscitation)

is a basic emergency procedure of artificial respirations and manual External cardiac Compression.

External Cardiac massage (compression)

is the rhythmic compression of the heart between the lower half of the sternum and the thoracic vertebral column.

ABCs of CPR

To establish an airway

To initiate breathing

To maintain Circulation

When an airway can not be established, reassess proper head position and assess airway obstruction.

Causes of Cardiopulmonary Arrest

1. Myocardial infarction

2. Heart failure

3. Electrocution

4. Drowning

5. Drug overdose

6. Anaphylaxis

7. Asphyxia

Nursing assessment

In CP arrest, assessment and intervention are quickly interwoven. The steps of CPR therefore include assessment and intervention.

Nursing Diagnosis

Ineffective tissue perfusion related to cessation of heart beat

Decrease Cardiac Out Put related to cessation of heart beat

Ineffective breathing pattern

Related to absent of respirations

Outcome:

Adequate oxygenation until heartbeat and respiration are restored.

Improving skin color, palpable pulse, and spontaneous respirations.

Types of Administering Artificial Respiration

Mouth- to Mouth pinch victims nostrils with thumb and Index finger and occlude mouth with nurses mouth.

Mouth to Nose Keep victims head tilted with one hand on forehead. Use other hand to lift the jaw and close mouth. Seal rescuers lips around victims noses, and blow.

Ambu- bag Use proper size face mask and apply it under chin up and over victims mouth and nose.

INTERVENTION

A. OPEN THE AIRWAY

1.When cardiopulmonary arrest is suspected, tap the victim urgently and ask are you okay

> Determine breathlessness and carotid or brachial (use with infant) pulse.

2. If no response, call for someone to contact of the emergency service.

3. Place the victim supine on a firm flat surface.

4. Open the airway by applying pressure to the forehead with one hand and using the other hand to lift the chin forward (head tilt chin lift maneuver) if no neck injury.

5. Use jaw thrust maneuver is done by lifting the lower jaw with both hands

B. CHECK FOR BREATHING (LOOK, LISTEN, FEEL)

6. Put your ear near the victims nose and mouth to listen and feel for breathing for 3-5 seconds. Watch to see if the chest rises and falls.

7. If the victim is not breathing give two slow breath at the rate of 1.5 2.0 seconds per breath. To do this first pinch the nostril shot, take a deep breath, seal your mouth around the victims and breath slowly 2 full seconds into the victims mouth.

> The appropriate volume of air causes a minimal rise of victim chest.

> If the chest does not rise, treat for airway obstruction

a. Lift the jaw and swift a finger through the mouth to try to remove the object.

b. Tilt the head back lift the chin, pinch the nostrils and try to ventilate the victim by breathing into the mouth once. If the airway is still obstructed, attempt of ventilation fail. Reposition the head and attempt once more to ventilate, If unsuccessfully proceed to the next step.

c. Straddle the victims thighs, place one hand on top of the other and deliver up to five abdominal thrust in the same area as described for Heimlich maneuver.

Repeat these steps until the airway is clear, once the airway is open CPR may be necessary to restore cardiac and respiratory function.

C.CHECK FOR CIRCULATION

1. Check the carotid artery on the side of the neck nearest you.

2. If there is no pulse, begin cardiac compressions to restore circulation. Locate the proper place to compress. Run the middle finger along the lower rib margin to the notch where the rib meet the sternum (xiphoid process).

Place the index finger next to the middle finger on the lower part of the sternum. Place the heel of the other hand next to the index finger Place the hand used to locate the tip of the sternum over the other hand. Lean over the victim so that your shoulders are above your hands and your arms are straight. Apply pressure to depress the sternum, counting one and two and three and four and five for 15 compressions. Depth of compression

Adult and adolescent 4-5cm ( 1 /2 to 2 inches)

Older child 3 4 cm ( 1 1 inches)

Toddler and pre-schooler 2-4 cm (3/4 to 1 inches)

Infant 1 2 cm ( to 1 inch)

Proper Rate of Compression

Adult and adolescent 80 to 100 rate per minute

Child at least 100 per minute

Infant at least 00 per minute

Mouth-to-Mouth and ambu bag Ventilation

Adult and adolescent 80 to 100 per minute (12/mins)

Older child every 4 seconds (15 / mins)

Child every 5 seconds (20 / mins)

Keep your hands in contact with the chest at all times At the completion of 15 compressions, ventilate the victim twice.10. Perform four cycles of 15 compressions and 2 ventilations and the reassess circulation at the carotid artery for 5 seconds.

11. If there is no carotid pulse resume CPR with 15 compression followed by 2 ventilations until help arrives.

Two rescuer CPR

If two trained people are present to perform CPR, one rescuer compresses the chest 15 times, then pauses briefly for the second rescuer to ventilate the victims twice. The compressor calls for a switch and trades places with the ventilator at the end of the cycle.

Recovery position

The unresponsive victim who is breathing should be log rolled to one side. (the recovery position)

Documentation

When emergency assistance arrive, provide information about the victim and the incident, including time that elapsed, intervention performed and victim response. Identify yourself and tell how you can be reached if additional information is needed.

INFANT CHEST COMPRESSION

Indications

Chest compression should be performed if the heart rate is:

1. Less than 60 or

2. between 60 to 100 and falling despite adequate ventilation 2 Methods of Chest Compression

1. Two thumb method

2. Two finger Method

Landmarks

Apply the fingers or thumbs over the lower third of the sternum. Above one fingers breath below the inter nipple line. Compressor performed anywhere near the xiphoid process are likely to cause visceral damage.

Rate = 90 per minute

Ratio

Three chest compression to one ventilation (3:1), resulting in 90 compressions and 30 ventilations.

Depth

2-3 cm, which is approximately 1/3 of the anterior-posterior chest diameter.

Action

Action should be well controlled, not be jerky or erratic, as this will likelihood of trauma.

The chest wall should be allowed to return fully to its relaxed position after each compression to encourage venous return to the heart.

Two thumb method

Position both thumbs over the lower third of the sternum, one fingers breath below the inter-nipple line. The thumbs may be placed side by side or overlapping in smaller babies.

Encircle the chest with both hands, giving support to the babies back.

Apply pressure to the thumbs only. Do not put pressure on the rib cage using a squeezing action as this makes compressions inefficient and may cause trauma

Perform compressions at the depth and rate prescribed.

Two Finger Method

The baby must be on a firm, flat surface.

Place the index and middle finger on the lower third of the sternum.

The finger must be perpendicular to the chest

Perform compressions at the depth and rate prescribed above

Re assessment of the baby

After one minute of compressions estimate the heart rate. If the rate is

100 and above, discontinue compressions and reassess respiratory activity and color.

Unchanged or falling despite adequate ventilation and chest compressions give adrenaline.

In hospital Cardiac arrest

Many hospitals have prepared teams of personnel, including physicians, nurses, anesthesiologists, and technicians who can be called to give immediate and complete care in the event of cardiac arrest

Discontinue CPR

1. EMS arrived

2. The rescuer is too exhausted

3. The length of initiation of CPR is 30 minutes

Complications of CPR

1. Fracture of the ribs

2. Fractured sternum

3. Costochondral separation

4. Lung contusion

5. Lacerations of the liver

Signs to be reported to the physicians after CPR

1. Labored breathing

2. Paradoxical pulse

3. Muffled heart sounds

4. Drop in blood pressure

Emergency Cart is a especially equipped cart on which all necessary emergency items are available such as:

a. ECG machine

b. Suction device

c. Oxygen

d. Defibrillator

e. Airway or ambu or other breathing bag

f. Laryngoscope, variety of endothracheal tubes

g. Cut down set

h. Intravenous fluids

i. Tracheostomy set

j. Emergency drugs

C.HEMORRHAGE

Hemorrhage- is an uncommon yet serious complication of surgery that

can result in death.

Classification of hemorrhage:

A. Time Frame.

Primary - hemorrhage occurs at the time of surgery

Intermediary -hemorrhage occurs during the first few hours

after surgery when the rise of Bp to its normal

level dislodges insecure clots from untied

vessels.

Secondary- hemorrhage may occur some time after surgery if a

ligature slips because a blood vessel was

insecurely tied, became infected, or was eroded

by a drainage shock

B. Types of Vessel

a. Capillary- hemorrhage is characterized by slow, general ooze.

b. Venous- darkly colored blood bubbles out quickly.

c. Arterial- blood is bright red and appears in spurts with each

heartbeat.

C. Viability

a. Evident- hemorrhage is on the surface and can be seen

b. Concealed- hemorrhage is in a body cavity and cannot be seen.

Clinical Manifestation when there is a blood loss:

Apprehensive

Restless

Thirsty

The skin is cold, moist and pale

Increase pulse rate

Decrease temperature

Respiration is rapid and deep

Sign and Symptoms of Hemorrhage

1. apprehension, restless

2. Cold, clammy skin

3. Temperature drops

4. Sweaty

5. Pale skin

6. Rapid, Thready pulse

7. Thirst

8. Rapid and deep respirations

9. Circumoral pallor, spots appear before the eyes

10. Dizziness

11. Hypotension

12. Weak

13. Decreasing alertness

Signs and symptoms of internal bleeding

1. Pain

2. Hematemesis

3. Dyspnea

4. Decreasing alertness

5. Pale skin

If hemorrhage progresses untreated:

Cardiac output decreases

Arterial and venous BP and Hgb level fall rapidly

Lips and conjunctiva become pallid

Spots appear before the eyes

Tinnitus

Patient grows weaker but remain conscious

Management

(External bleeding)

1. Direct continuous pressure

2. Sterile dressing is placed over the wound or clean cloth

3. Elevate and immobilize the injured part (unless fracture is suspected)

4. Apply indirect pressure, that is pressure to the main artery

Management:

(Hemorrhage)

1. Cut the patients clothing away quickly and carry out a rapid physical examination

2. Apply firm pressure over the bleeding area of the artery involved

3. Apply a firm pressure dressing. Elevate and immobilize an injured part.

4. Place patient in the most physiologically desirable position for shock

a. Elevate the head to a pillow

b. Keep the trunk horizontal

c. Elevate lower extremities about 20 to 30 degrees keeping knees straight.

5. Insert an intravenous cannula to provide means of blood replacement.

a. Withdraw blood sample for analysis, typing and cross matching

b. Give replacement fluids, isotonic electrolyte solution, blood

1. Fresh blood is infused when there is massive blood loss.

2. Additional platelets or clotting factors are given.

3. Warm the blood (commercial warmer or basin of water)

c. Rate of infusion depends on the severity of blood loss and clinical evidence of hypovolemia

6. Take the following step for internal bleeding

a. Suspect internal bleeding in patient with

Hypovolemic Shock with no external signs of

bleeding.

b.Give whole blood or plasma expanders at the rate of

blood Loss.

c.Apply a tourniquet only as a last resort when the

hemorrhage can not be controlled by any other

method

Tag the patient (with a skin marking pencil or adhesive on his forehead) with a T stating the location of the tourniquet and the time applied.

7.Watch for cardiac arrest.

Epistaxis nosebleed

Blood may come from the anterior or posterior portion of the nose.

Most anterior nosebleeds respond to pressure.

Intervention

1. Instruct the patient to sit down and lean the head forward.

2. Pinch the nostrils shut for at least 10 minutes

3. Advise the patient not to blow or pick at the nose for several hours.

D. SHOCK

It is a condition in which systemic blood pressure is inadequate to deliver oxygen and nutrients to support vital organs and cellular function.Is a life threatening condition with variety of underlying causes.It is characterized by inadequate tissue perfusion that, if untreated results in cell death.

CLASSIFICATION OF SHOCK

1. Hypovolemic Shock - occurs when there is a decrease in the intravascular volume. It is the most common type of shock; it is characterized by a decreased intravascular volume of 15% to 25%. This represents a loss of 750 to 1,300 ml of blood in a 70kg person.

Risk factors:

External: Fluid losses

Vomiting

Diarrhea

Diuresis

Diabetic insipidus

Trauma Surgery

Internal:FluidShifts

Hemorrhage

Burns

Ascites

Peritonitis

Dehydrartion

Categories of Causes of Hypovolemic Shock

1. Absolute hypovolemia occurs as a result of external losses of fluid.

2. Relative hypovolemia occurs as a result of the internal shifting of

fluid between the bodys two compartments, which is known as third spacing.

Third spacing is when the fluid of the intravascular space relocates to the extra-vascular space, causing edema

Sign and Symptoms per Stage

1.Compensatory Stage

Occurs with a fluid loss of 15% to 30% or 750 to 1500 ml

The goal of this stage is to restore oxygenation and perfusion to the cells

Patient may exhibit:

Normal BP reading and narrowed pulse pressure (the difference between the systolic and diastolic BP which is normally 40 mmHg

Tachycardia

Tachypnea

Hypoxia

Decrease Urinary Output

Thirst

Pale

Cool skin

Delayed Capillary refill

Changed in LOC (confusion, restlessness, anxiousness)

2.Progressive Stage of Shock

Occurs with the fluid loss of 30% to 40% or 150 to 200 ml

In this stage the compensatory mechanism fail and tissue perfusion becomes ineffective for the body organ to function.

Patient may exhibit:

Heart rate continues to increase

Vasoconstriction

Hypotensive

Narrowed pulse pressure

Oliguria worsen

Increasingly lethargic, confused and comatose

During this stage, organs become dysfunctional and all body system is affected. As one organ fails, the others eventually become dysfunctional, leading to multi-organ dysfunction syndrome (MODS)

3.Refractory or Irreversible Stage of Shock

The body organ are no longer responsive to treatment and multi-pleorgan failure ensures

The compensatory mechanism completely and organ failure occurred

The patient exhibit:

Severe tachycardia becomes bradycardia

Continued hypotension

Cardiopulmonary arrest

Unresponsive

Edema

Oliguria at Anuria

Failure of other body system, the patient has 90% to 100% mortality rate when only 3 body system fails

GOAL:

Restore homeostasis and intra-vascular volume

Medical management:

Treatment of the underlying cause

Fluid and blood replacement

Redistribution of fluid

Pharmacologic therapy

Nursing Management:

Ensuring safe administration of prescribed fluids and medications

Documenting their administration and effects

Monitoring for signs of complication and side effects of treatment

Reporting signs early in treatment

Administering blood and fluids safely

2. Cardiogenic Shock occurs when the heart has an impaired pumping ability; it may be coronary and no coronary origin. It also occurs when the hearts ability to contract and to pump blood is impaired and the supply of oxygen is inadequate for the heart and tissues.

Causes:

Coronary Cardiogenic Shock

Non coronary Cardiogenic Shock

Clinical Manifestations:

Angina

Dysrhythmias

Hemodynamic instability

Medical management:

Correction of underlying causes

Initiation of first line treatment involves the ff:

a.Supplying supplement oxygen

b.Controlling chest pain

c.Administering Vasoactive medication

d.Controlling heart rate with medication

Implementing mechanical cardiac support Mechanical assistive devices

Nursing Management:

Preventing cardiogenic shock

Monitoring hemodynamic status

Administering Medications and Intravenous fluids

Maintaining intra-aortic balloon counterpulsation

Enhancing safety and comfort

Goal of Treatment

To restore blood flow and oxygenation

Treatment

Cardiac revascularization

Thrombolytic therapy

Angioplasty

Bypass surgery

Circulatory support for mechanical devices

Intraaortal Balloon Pump (IABP)- works by inflating during diastole and deflating during systole

Left ventricular Assist Device (LVAD)- increases CO by helping the left ventricle pump blood to the periphery. Allows the heart to rest and not work so hard while the body tries to repair the body.

Pharmacologic Intervention

Dopamine (Intropin) Increases renal perfusion at lower doses and causes an increase in CO, heart rate and, and systemic arterial pressure at higher doses, which increases the pumping action of the heart (positive inotropic).

Dobutamine (Dobutrex) Increases the pumping action of the heart (positive inotropic) and CO and decreases ventricular filling pressure.

Norepinephrine (levophed) A profound vasoconstrictor that is used to patient with extremely low systolic pressure (80mmHG on blood gas analysis an Oxygen saturation of >90% are both therapeutic goals.

Patient condition may require use of mechanical ventilation.

3. NUEROGENIC SHOCK

Also known as the spinal shock.

It is a rare shock.

The SNS is disrupted.

Caused by a loss of sympathetic tone.

Patient exhibit:

Bradycardia

Decreased cardiac output

Hypotension

Hypothermia

Goal : To improve tissue perfusion

Management:

Maintain patient ABCs

IV fluid for volume replacement

Initiating vasopressor to control BP

Administer atropine sulfate for bradycardia

Provide rewarming measures

4.SEPTIC SHOCK

- Is a shock state that occurs when sepsis is present in a patient.

- Severe infection

Characteristic:

Tachycardia

Hyperthermia or hypothermia

Hypotension

Increase RR

Tachypnea

Fatigue

Skin lesions

Agitated, confused, lethargic, disoriented, unarousable

Multiorgan dysfunction syndrome

Treatment:

Maintain a patent airway

Administer oxygen

Monitor Hemodynamic

Provide IV access

Support BP with fluid and medications

Obtain cultures

Administer appropriate antibiotic therapy

Administer an antipyretic

Conditions Predisposing to Septic Shock

Malnutrition

Large open wounds

Infection with resistance microorganism

Receiving chemotherapy

5. ANAPHYLACTIC SHOCK Is caused by a severe allergic reaction when a patient who has already produced antibodies to a foreign substance develops a systematic antigen-antibody reaction.

Risk factors: Penicillin sensitivity

Transfusion reaction

Insect stings allergy

Latex sensitivity

Medical Management:

Requires removing the causative antigen

Endotracheal intubation or tracheotomy

IV lines are inserted

Nebulized medication given in IV

Nursing Management:

Assess pt. for allergies

Assess the patients understanding of previous reaction and steps taken by the patients

Observe for any allergic reaction

E.WOUNDS

It is a type of physical trauma where in the skin is torn, cut or punctured (an open wound), or where blunt force trauma causes a contusion (a closed wound). In pathology, it specifically refers to a sharp injury which damages the dermis of the skin.

Types of Wounds

1. Abrasions- also called scrapes, they occur when the skin is rubbed away by friction against another rough surface (e.g. rope burns and skinned knees).

2. Avulsions-occur when an entire structure or part of it is forcibly pulled away, such as the loss of a permanent tooth or an ear lobe. Explosions, gunshots, and animal bites may cause avulsions.

3. Contusions- also called bruises, these are the result of a forceful trauma that injures an internal structure without breaking the skin. Blows to the chest, abdomen, or head with a blunt instrument (e.g. a football or a fist) can cause contusions.

4. Crush wounds- occur when a heavy object falls onto a person, splitting the skin and shattering or tearing underlying structures.

5. Cuts- Slicing wounds made with a sharp instrument, leaving even edges. They may be as minimal as a paper cut or as significant as a surgical incision.

6. Lacerations- also called tears, these are separating wounds that produce ragged edges. They are produced by a tremendous force against the body, either from an internal source as in childbirth, or from an external source like a punch.

7. Missile wounds- also called velocity wounds, they are caused by an object entering the body at a high speed, typically a bullet.

8. Punctures- these are deep, narrow wounds produced by sharp objects such as nails, knives, and broken glass.

Signs of Wounds

Bleeding

Loss of feeling or function below the wound site

Pain

Management

FOR MINOR CUTS

1. Wash your hands with soap to avoid infection.

2. Wash the cut thoroughly with mild soap and water.

3. Use direct pressure to stop the bleeding.

4. Apply an antibacterial ointment.

5. If the cut is likely to get dirty or be re-opened by friction, cover it (once the bleeding has stopped) with a bandage that will not stick to the injury.

FOR MINOR PUNCTURES

1. Wash your hands.

2. Use a stream of water for at least five minutes to rinse the puncture wound. Wash with soap.

3. Look (but DO NOT probe) for objects inside the wound. If found, DO NOT remove -- go to the emergency room. If you cannot see anything inside the wound, but a piece of the object that caused the injury is missing, also seek medical attention

DO NOT:

DO NOT assume that a minor wound is clean because you can't see dirt or debris inside. Wash it.

DO NOT breathe on an open wound.

DO NOT try to clean a major wound, especially after the bleeding is under control.

DO NOT remove a long or deeply embedded object. Seek medical attention.

DO NOT probe or pick debris from a wound. Seek medical attention.

DO NOT push exposed body parts back in. Cover them with clean material until medical help arrives.

Call your doctor immediately if:

The wound is large or deep, even if the bleeding is not severe.

You think the wound might benefit from stitches (the cut is more than a quarter inch deep, on the face, or reaches bone).

The person has been bitten by a human or animal.

A cut or puncture is caused by a fishhook or rusty object.

You step on a nail or other similar object

An object or debris is embedded -- DO NOT remove yourself.

The wound shows signs of infection (warmth and redness in the area, a painful or throbbing sensation, fever, swelling, or pus-like drainage).

You have not had a tetanus shot within the last 10 years

To avoid infection and aid healing:

Apply pressure with a clean cloth to stop bleeding

Clean the wound with water

Use an antibiotic ointment to prevent infection

Bandage the wound if it's in an area that might get dirty

Watch for swelling and redness

Get a tetanus booster if you are due for one

F. TRAUMA

The unintentional or intentional wound or injury inflicted on the body from a mechanism against which the body cannot protect itself, is the third leading cause of the deaths in children and adults younger than 44 years old in other countries.

Types of Trauma

1. HEAD TRAUMA

Is a trauma to the head, that may or may not include injury to the brain Signs and symptoms

Severe head or facial bleeding

Change in level of consciousness for more than a few seconds

Black-and-blue discoloration below the eyes or behind the ears

Cessation of breathing

Confusion

Loss of balance

Weakness or an inability to use an arm or leg

Unequal pupil size

Repeated vomiting

Slurred speech

If severe head trauma occurs:

Keep the person still. Until medical help arrives, keep the person who sustained the injury lying down and quiet in a darkened room, with the head and shoulders slightly elevated. Don't move the person unless necessary and avoid moving the person's neck.

Stop any bleeding. Apply firm pressure to the wound with sterile gauze or a clean cloth. But don't apply direct pressure to the wound if you suspect a skull fracture.

Watch out for breathing changes and alertness. If the person shows no sign of circulation (breathing, coughing, or movement) begin CPR

Management

Immobilize the patient to insure no further damage to the spine or nervous system

Insert an airway to insure uninterrupted breathing, and perform endotracheal intubation if indicated. One or more IVs will be inserted to maintain perfusion status. In some cases medications may be administered to sedate or paralyze the patient to prevent additional movement which may worsen the brain injury.

Primary treatment involves controlling elevated intracranial pressure. This can include sedation, paralytics, cerebrospinal fluid diversion. Second line alternatives include decompressive craniectomy (Jagannathan et al. found a net 65% favorable outcomes rate in pediatric patients), barbiturate coma, hypertonic saline and hypothermia

2.CHEST TRAUMA (or thoracic trauma)

Is a serious injury of the chest. Thoracic trauma is a common cause of significant disability and mortality. Thoracic injuries account for approximately 25% of all trauma-related deaths.

TYPES OF CHEST TRAUMAINJURY

CAUSE

S/SX

FIRST AID

Rib Fracture

Blow to chest

Pain on inspiration, local tenderness

Transport

Flail Chest

Rib fractured in more than one place, chest wall becomes unstable

Paradoxical respiration, Respiratory distress, Chest pain

Apply external pressure, Sand bed pillow, Give O2, transport with flail side down

Open Pneumothorax

Penetrating trauma to chest, loss of negative intra-thoracic pressure as air moves in & out of wound

Sucking sound on chest wall during inspiration tracheal deviation

Cover wound with occlusive dressing exhalation given O2.

Single Pneumothorax

Laceration of lungs, Hyperinflation (blast injuries, driving accident) Loss of negative intra-thoracic pressure

Sudden onset of chest pain, Decreased breath sound of affected area, dyspnea, tachypnea

Semi-fowlers or fowlers position, Give O2.

Tension Pneumothorax

Complication of another type of pneumonia, air enters to the pleural cavity but cant escape

Respiratory distress, paradoxical chest movement, neck vein distention, tracheal deviation to unaffected side

Maintain airway breathing, give oxygen

Hemothorax

Blunt and penetrating injuries, injuries to major blood vessels and heart,Blood collects to the pleural cavity

Decreased breath sounds and dyspnea

Treat shock give oxygen

G. INJURIES

A. Intra Abdominal InjuriesCategories:

1. Penetrating abdominal injury this results in a high incidence of injury in hollow organs particularly the small bowel. 2. Blunt abdominal injury- results from motor vehicle crashes, falls and blows. This is commonly associated with extra abdominal injury to chest. Head and extremities B. Crash Injuries

Crash injuries occur when a person is caught between objects run over by moving vehicle or compressed by machinery.

Assessment

The patient is observed for the following:

Hypovolemic shock

Paralysis of the body

Erythema and blistering part

Damaged body part

Renal dysfunction .

Management

Maintain patent airway

Observed for renal insufficiency

Elevate extremities to relieve swelling and pressure.

Medication for pain and anxiety

C. Multiple injuries

Multiple injuries are associated with increased severity, higher mortality and often require more complex care and facilities. Previous data summary methods included selecting a primary injury, predefining injury combinations and recording them and coding multiple injury with no further detail. These methods all have serious flaws.

Management

1. Maintain patent airway.

2. Loose patients clothing.

3. Assess head and neck for injury.

4. Splint fractures

5. Prevent and treat hypovolemic shock

D. Musculoskeletal Injuries

Musculoskeletal injuries can occur from both blunt and penetrating trauma. Injuries may include contusions, cramps, dislocations, fractures, spasm, sprains, strains and/or subluxations. Early proper treatment of these injuries may prevent long term morbidity and disability. Major injuries to the musculoskeletal system ( e.g., pelvic fractures and hip dislocations) may cause shock due to hemorrhage, injury to adjacent nerves and blood vessels and infection due to the presence of an open fracture. Fractures of the humerus, pelvis or femur take priority over other musculoskeletal injuries as do fractures or dislocations involving circulatory or neurologic deficits

ASSESSMENT / TREATMENT PRIORITIES

1. Maintain appropriate body substance isolation precautions.

2. Maintain an open airway and assist ventilations as needed. Assume

Spinal injury when appropriate and treat accordingly.

3. Administer high concentration oxygen.

4. Determine patient's hemodynamic stability and symptoms. If

indicated, continually assess using O-P-Q-R-S-T model, and the

Level of Consciousness, ABCs and Vital Signs.

5. Assess the neurovascular status (motor, sensory and circulation)

distal to the injury before and after proper immobilization.

6. If no palpable, distal pulse is present, apply gentle traction along the

axis of the extremity distal to the injury until the distal pulse is

palpable and immobilize in place.

Note: This does not apply to dislocations.

7. Immobilize all painful, swollen and/or deformed extremity injuries

(e.g. fractures, sprains, strains and/or dislocations) involving joints, in

the position found.

8. All jewelry should be removed from an injured extremity.

9. Obtain appropriate S-A-M-P-L-E history related to event.

10. Prevent / treat for shock.

11. Monitor and record vital signs

TREATMENT

BASIC PROCEDURES

1. Maintain appropriate body substance isolation precautions.

2. Maintain an open airway and assist ventilations as needed. In cases

of suspected head/neck injury, assure cervical spine

stabilization/immobilization. Airway may include repositioning of the

airway, suctioning or use of airway adjuncts (or pharyngeal airway /

nasopharyngeal airway) as indicated.

3 Administer high concentration oxygen.

4. Control/stop any identified life threatening hemorrhage (direct

pressure, pressure points, etc.).

5. Assess the neurovascular status (motor, sensory and circulation)

distal to the injury before and after proper immobilization.

6. If no palpable, distal pulse is present apply gentle traction along the

axis of the extremity distal to the injury until the distal pulse is

palpable and immobilize in place.

Note: This does not apply to dislocations.

7. Immobilize painful, swollen and/or deformed extremity injuries (e.g.

fractures, sprains, strains and/or dislocations) involving joints, in the

position found. Bones adjacent to each injured joint must be fully

immobilized, as well as supporting and immobilizing the injured joint.

Joints adjacent to each injured bone must be fully immobilized, as

well as supporting and immobilizing the injured bone(s).

8. All jewelry should be removed from an injured extremity.

9. For hemodynamically unstable patients, showing signs and/or

symptoms of shock, with suspected pelvic fracture(s), contact

MEDICAL CONTROL for potential utilization of PASG/MAST.

10. Activate ALS intercept, if deemed necessary and if available.

11. Initiate transport as soon as possible with or without ALS.

12. Monitor and record vital signs every 5 minutes at a minimum, if

unstable, or every 15 minutes if stable.

13. If patients BLOOD PRESSURE drops below 100 systolic: treat for

shock.

14. Notify receiving hospital.

INTERMEDIATE PROCEDURES

1. Maintain appropriate body substance isolation precautions.

2. Maintain an open airway and assist ventilations as needed. In cases

of suspected head/neck injury, assure cervical spine

stabilization/immobilization. Airway may include repositioning of the

airway, suctioning or use of airway adjuncts (oropharyngeal airway /

nasopharyngeal airway) as indicated.

3. Administer oxygen by nasal cannula or mask as determined by

patient's condition.

4. Control/stop any identified life threatening hemorrhage (direct

pressure, pressure points, etc.).

5. Assess the neurovascular status (motor, sensory and circulation)

distal to the injury before and after proper immobilization.

6. If no palpable, distal pulse apply gentle traction along the axis of the

extremity distal to the injury until the distal pulse is palpable and

immobilize in place.

Note: This does not apply to dislocations.

7. Immobilize painful, swollen and/or deformed extremity injuries (e.g.

fractures, sprains, strains and/or dislocations) involving joints, in the

position found. Bones adjacent to each injured joint must be fully

immobilized, as well as supporting and immobilizing the injured joint.

Joints adjacent to each injured bone must be fully immobilized, as well

as supporting and immobilizing the injured bone(s).

8. All jewelry should be removed from an injured extremity.

9. ALS STANDING ORDERS

a. Provide advanced airway management (if indicated).

b. Initiate IV Normal Saline while in transport. (if indicated).

c. If patients BLOOD PRESSURE drops below 100 systolic: treat

for shock.

Administer a 250 cc bolus of IV Normal Saline.

10. Contact MEDICAL CONTROL. Medical Control may order:

a. administration of additional fluid.

b. application/inflation of PASG/MAST.

11. Activate Paramedic intercept, if deemed necessary and if available.

12. Initiate transport as soon as possible with or without Paramedics.

13. Notify receiving hospital.

PARAMEDIC PROCEDURES

1. Maintain appropriate body substance isolation precautions.

2. Maintain an open airway and assist ventilations as needed. In cases

of suspected head/neck injury, assure cervical spine stabilization

immobilization. Airway may include repositioning of the airway,

suctioning or use of airway adjuncts (or pharyngeal airway /

nasopharyngeal airway) as indicated.

3. Administer oxygen by nasal cannula or mask as determined by

patient's condition.

4. Control/stop any identified life threatening hemorrhage (direct

pressure, pressure points, etc.).

5. Assess the neurovascular status (motor, sensory and circulation)

distal to the injury before and after proper immobilization.

6. If no palpable, distal pulse apply gentle traction along the axis of the

extremity distal to the injury until the distal pulse is palpable and

immobilize in place.

Note: This does not apply to dislocations.

7. Immobilize painful, swollen and/or deformed extremity injuries (e.g.

fractures, sprains, strains and/or dislocations) involving joints, in the

position found. Bones adjacent to each injured joint must be fully

immobilized, as well as supporting and immobilizing the injured joint.

Joints adjacent to each injured bone must be fully immobilized, as well

as supporting and immobilizing the injured bone(s).

8. All jewelry should be removed from an injured extremity

9. ALS STANDING ORDERS

a. Provide advanced airway management (if indicated).

b. Initiate IV Normal Saline, titrate IV infusion rate to patient's

hemodynamic status.

c. Application/inflation of PASG/MAST (if indicated).

d. If patients BLOOD PRESSURE drops below 100 systolic: treat for

shock.

Administer a 250 cc bolus of IV Normal Saline.

10. MEDICAL CONTROL may order:

a. Administration of additional IV Normal Saline.

b. Morphine Sulfate 2-5 mg IV Push for pain control related to

an isolated long bone injury. May be repeated at discretion of

Medical Control.

11. Initiate transport as soon as possible.

12. Notify receiving hospital.

H. FRACTURES

- is a break in the continuity of the bone.

Classification

According to the appearance of the part and according to whether there is soft tissue wound is associated with the break

Closed (simple) fracture the skin has not been broken

Open (compound) fracture bone has broken through the skin or there is a wound which extends to the fracture site.

According to the appearance of the broken bone in Open or close fracture

Green stick fracture - This is an incomplete fracture that occurs only in a child

Transverse fracture- The fracture line is straight across at a right angle to the long axis of the bone

Oblique fracture the fracture line cross the bone at an oblique angle

Spiral fracture The fracture line twists around and through the bone

Comminuted fracture - The bone is broken into more than two pieces

Impacted fracture -The broken end of the bone are jammed into each others

Complicated fracture -this means there is another associated injury along with the fracture. That damage may include nerve, blood vessels and vital organs, e.g. when a casualty has a broken rib it may puncture the lung and that is the complication to the fracture.

Signs:

1. Deformity An arm or leg may be in an un natural position or may be angulated where there is no joint. The chest wall of the skull is caved in

2. Tenderness is usually sharply localized at the site of the break. This valuable sign is known as point tenderness. The point tenderness can be located gently pressing along the bone with the tip of the finger

3. Grating or crepitus this is a sensation that can be felt when the broken ends of the bone rub together.

4. Swelling and dislocation

Swelling may be due to edema (increase fluid in soft tissue) and may not become obvious in several hours.

Swelling may be due to hemorrhage (increase blood in the tissue)

5. Loss of use

6. Exposed fragment In the open or compound type of fracture bone fragments may protrude through the skin or be seen in the depths of the wound

Dislocation is the displacement of the bone ends at a joint so that the

joint surface are no longer in contact.

A joint consists of opposing ends of bone, covered by cartilage which are held together by a joint capsule, ligaments and tendons.

The capsule and the ligaments help provide stability to the joint

When there is a dislocation. The joint capsule is torn and one of the bone ends is dislodged from its normal position.

A complete dislocation causes tearing of the ligaments.

Frequently dislocated joint

A. Shoulder

B. Elbow

C. Fingers

D. Hip

E. Ankle

S/Sx of dislocation

1. Deformity of the joint

2. Pain or pressure at the joint

3. Pain on any attempted motion of the joint

4. Complete or nearly complete loss of movement of the joint

Signs of compress or lacerate nearby vessels in facture or Dislocation

1. Numbness or paralysis below the fracture or dislocation

2. Loss of the pulse below the fracture

3. Feel cold

Sprain is a partial tear of a ligament.

caused by a sudden twisting or stretching of the joint beyond the normal range of motion.

Two common areas of sprain are the ankle and knees

Ankle injury is usually caused by a sudden twisting of the foot being turned inward

Treatment: Immobilized the joint

Fracture and dislocation may be caused in many ways:

1. Direct injuries Falling on an arm, being struck by an auto mobile

2. Indirect injuries A blow received at some distance from a break usually inline with the axis of the bone. Example a hip can be fractured when the knee strikes a dashboard.

a. Twisting injuries a severe twisting force may result in a bad sprain, fracture or dislocation may be seen in the ankle and knees.

b. Powerful muscular contraction- sometimes muscles can contract so powerful that they actually avulse or pull away a small piece of bone.

3. Fatigue fractures- bones of the feet are particularly prone to fractures when they cannot tolerate repeated stress, as in a long march and they simply crack

4. Pathological fractures these fractures are due to localized disease process such as cancer which has weakened the bone.

Fracture treatment

Goal: To regain and maintain correct position and alignment

To regain the function of the involved part

To return the patient to his usual activities in the shortest

Time and at the least expense.

Process:

1. Reduction- setting the bone; refers to restoration of the fracture fragments into anatomic position and alignment

2. Immobilization maintains reduction until bone healing occurs

3. Rehabilitation regaining normal function of the affected part.

Management

Control external bleeding and protect the wound Ask the casualty not to move, make them comfortable Avoid twisting of the neck or spine, maintain the alignment of the spine Check for circulation into the limb beyond the facture Handle gently, do not attempt to straighten fractured limbs immobilize the fracture with pillows and blankets or use splints if necessary Seek medical assistance for transportation of the casualty Manage shock.Strain - involve injury to the muscles and tendons caused by

Excessive force, stretching or overuse.

If in doubt as to whether the casualty has a sprain, strain, fracture or dislocation always treat the injury as a fracture and never apply a compression bandage over a suspected broken bone

Management

REST:

Decreases the pain.

ICE:

HEAT:

This applied to the injury for 15-20 minutes intermittently for 12-36 hours minutes . Ensure there is a barrier between the ice and the skin. Ice helps to control the swelling and relieve pain.

After 24 hours, apply mild heat (15-30 minutes 4 times a day).

COMPRESSION:

A firm supportive figure 8 bandage is used to give even pressure over the injured area.

ELEVATION:

This reduces swelling as it slows the bleeding.

Splint can be any material or appliance which prevent movement

of a fractured or dislocated extremity.

Objective: To prevent motion of fragments of bone or of Dislocated

joints during transportation to Medical Facility.

Splint may prevent the following complications:

1. Damage to muscles, nerves, or blood vessels caused by broken ends of the bone.

2. Laceration of skin by broken bone, creating an open fracture (far more dangerous because of possible contamination of infection).

3. Restricted flow of blood as a result of pressure of bone ends on blood vessels

4. Excessive bleeding into the tissue around the fracture as a result of unstable bone ends

5. Paralysis of extremities due to fractured or dislocated vertebraeI. BANDAGING

Bandages are applied for the following reasons:

1. To keep dressing, poultice or splints in position

2. To give support to a limb or tissues.

3. To reduce or prevent swelling

4. To correct deformity

5. To control bleeding

6. To limit movement.

Principles of Bandaging

The test of a good bandage is:

1. It entirely covers the dressing and yet is not cumbersome to the patient.

2. It should be firm enough to keep the dressing in place yet not so tight that it causes discomfort, or impedes circulation.(except in case of a bandage applied to stop bleeding)

3. It is neat in appearance.

Patterns used in Bandaging

1. Circular turns, as used for head and trunk

2. Simple spiral, for parts of uniform thickness, e.g. fingers wrist

3. Reversed spiral used on limbs where, owing to varying thickness, a simple spiral bandage would not lie smoothly

4. Figure of eight. This may used on limbs instead of the reversed spiral, and for the hand and foot.

5. Spica used for the shoulder hi, and thumb

6. Divergent spica, for a flexed joint, e.g. elbow, knee, heel

7. Recurrent to cover tips of fingers or stump

8. Special bandages such as capeline for the head, eye, ear and breast bandages.

Bandage can be improvised by using any soft clean pieces of cotton cloth such as handkerchief, a towel or pieces of sheeting

Types of bandages

1. Roller

2. Triangular

3. Special, e.g. many tailed

Roller bandages

These are made of various materials such as gauze, open woven cotton, calico, flannel, crepe, elastoplast, rubber (used as a tourniquet) and plaster of paris.

Roller bandages should be rolled tightly and evenly, preferably using a bandage roller. Selvedges are to be avoided

Required Length and Width of Bandages

Part of Body

Width of bandages

Length of bandages

Finger

Hand

Arm

Foot

Leg

Body

Head

1/2 1 inches

1 2 inches

2 2 inches

1 - 3 inches

2-3 inches

3 6 inches

2 inches

1-3 yards

3 yards

7 9 yards

4 yards

9 yards

10 yards

6 yards

Rules for the Application of Roller Bandages

1. Have the patient in a comfortable position, and support the limb to be bandaged in the position in which it is to remain

2. Stand in front of the patient and the part to be bandaged, except when bandaging the head or back of the neck.

3. Hold the drum of the bandage in the right hand when bandaging a left limb, and vice versa.

4. Apply the outer side of the bandage to the part, holding the drum upper most.

5. Use pads where necessary to avoid pressure or skin surfaces touching, e.g. in axilla.

6. Unroll no more than two inches of bandage at a time and maintain even pressure.

7. See that the bandage is neither too tight nor too slack

8. Bandage from below upwards and within outwards over the front of the limb.

9. Apply each layer of the bandage so that it covers two thirds of the previous turn.

10. Finish in the front, not over the wound or a bony prominence, with a safety pin, adhesive plaster or stitching.

Triangular Bandages

It is made of strong cotton cloth. A piece 34-40 or one metre square, cut diagonally makes two bandages. The edges should be hemmed.

It is much used in first aid because it is more suitable than the roller bandage for improvisation.

It is also used as a sling to support the arm.

The long side is called the base and the corner opposite to it is the point.

The bandage may be applied opened out or it can be folded into a broad or narrow bandage.

To fold a Bandage

1. Bring the point down to the center of the base, then fold again in the same direction. This makes a broad bandages

2. Fold once again in the same direction to make a narrow bandage.

3. When not in use, the triangular bandage should be folded narrow, and then the two ends are folded to the center, and again in two, making a neat packet.

Fracture of the Mandible and Axilla (Bandaging)

J.ENVIRONMETAL EMERGENCY

i. HEAT STROKE

Heat stroke is defined typically as hyperthermia exceeding 41C, it is a medical emergency. Even with immediate treatment, it can be life-threatening or result in serious, long-term complications. After calling 911 or other emergency medical services.

Heatstroke occurs when the body fails to regulate its own temperature and body temperature continues to rise, often to 105 (40.6) or higher.

Signs of rapidly progressing heatstroke include:

Unconsciousness for longer than a few seconds.

Convulsion (seizure).

Signs of moderate to severe difficulty breathing.

A rectal temperature over 104 (40) after exposure to a hot environment.

Confusion, severe restlessness, or anxiety.

Fast heart rate.

Severe vomiting and diarrhea.

A.Types of Heat Stroke1.Exertional heat stroke

- Occurs in young individuals who engage in strenuous physical activity for a prolonged period of time in a hot environment.

EHS is characterized by hyperthermia, diaphoresis, and an altered sensorium, which may manifest suddenly during extreme physical exertion in a hot environment.

A number of symptoms (eg, abdominal and muscular cramping, nausea, vomiting, diarrhea, headache, dizziness, dyspnea, weakness) commonly precede the heat stroke and may remain unrecognized. Syncope and loss of consciousness also are observed commonly before the development of EHS.

EHS commonly is observed in young, healthy individuals (eg, athletes, firefighters, military personnel) who, while engaging in strenuous physical activity, overwhelm their thermoregulatory system and become hyperthermic. Because their ability to sweat remains intact, patients with EHS are able to cool down after cessation of physical activity and may present for medical attention with temperatures well below 41C.

Risk factors that increase the likelihood of heat-related illnesses include a preceding viral infection, dehydration, fatigue, obesity, lack of sleep, poor physical fitness, and unacclimatization. While unacclimatization is a risk factor for heat stroke, EHS also can occur in acclimatized individuals who are subjected to moderately intense exercise.

EHS also may occur because of increased motor activity due to drug use, such as cocaine and amphetamines, and as a complication of status epilepticus.

B. Classic non exertional heat stroke Commonly affects sedentary elderly individuals, persons who are chronically ill and very young persons. Classic NEHS occurs during environmental heat waves and is more common in areas that have not experienced a heat wave in many years.

Classic NEHS is characterized by hyperthermia, anhidrosis, and an altered sensorium, which develop suddenly after a period of prolonged elevations in ambient temperatures (ie, heat waves). Core body temperatures greater than 41C are diagnostic, although heat stroke may occur with lower core body temperatures.

Numerous CNS symptoms, ranging from minor irritability to delusions, irrational behavior, hallucinations, and coma have been described.

Anhidrosis due to cessation of sweating is a late occurrence in heat stroke and may not be present when patients are examined.

Other CNS symptoms include hallucinations, seizures, cranial nerve abnormalities, cerebellar dysfunction, and opisthotonos.

Patients with NEHS initially may exhibit a hyperdynamic circulatory state, but, in severe cases, hypodynamic states may be noted.

Classic heat stroke most commonly occurs during episodes of prolonged elevations in ambient temperatures. It affects people who are unable to control their environment and water intake (eg, infants, elderly persons, individuals who are chronically ill), people with reduced cardiovascular reserve (eg, elderly persons, patients with chronic cardiovascular illnesses), and people with impaired sweating (eg, patients with skin disease, patients ingesting anticholinergic and psychiatric drugs). In addition, infants have an immature thermoregulatory system, and elderly persons have impaired perception of changes in body and ambient temperatures and a decreased capacity to sweat.

Both types of heat stroke are associated with a high morbidity and mortality, especially when therapy is delayed.

Prevention of heat stroke1. A variety of human factors should be taken into account, such as acclimatization, general health and salt intake, peculiarities of religious devotion and liability to neglect, regulations intended to promote public health.

2. Athletes or pilgrims should be informed of the work load and the level of heat stress they may encounter, and of the risks of heat stroke.

3. A period of acclimatization is recommended before vigorous physical activity and/or severe exposure is risked.

4. The level of activity should be matched to the ambient temperature, and physical exertion should be avoided or at least minimized during the hottest hours of the day.

5. The opportunity for voluntary ingestion of water may be limited, thus delaying restitution from thermal dehydration, electrolytes should also be replaced in case of profuse sweating.

6. Proper clothing is also an important measure. Clothes made of fabrics which are both water-absorbent and permeable to air and water vapor facilitates heat dissipation.

Managementa. Emergency Care

1. Immersion in cool or iced water with skin massage is a classic technique for cooling heat stroke patients. Both have demonstrated effectiveness in lowering body temperature. Ice water probably produces the most rapid rate of cooling. However, ice water is an uncomfortable environment in which to work and, in the field, is very difficult to obtain.

Circulating cooling blankets (unlikely to be available in the field situation) will also lower body temperature. Although cooling blankets have the advantage of maintaining a dry working environment, their limited contact surface provides slower cooling than immersion or surface wetting techniques. Their best use is probably maintaining normal body temperature in the period after resusitation and rapid cooling where temperature instability is characteristic.

2. Invasive cooling techniques have been tried including ice water lavage or enemas and peritoneal lavage with cool fluids. These techniques do not provide faster cooling and have the additional disadvantages of potential complications and substantial inappropriate fluid loads. These techniques are not recommended.

3. Heat stroke patients usually do not require aggressive fluid resuscitation. Fluid requirements of 1 to 1.5 liters in the first few hours are typical. Over-replacement carries the risk of congestive heart failure, cerebral edema and pulmonary edema. Since heat stroke patients are frequently hypoglycemic, the initial fluid should include dextrose.

Hypotensive patients who do not respond to saline should receive inotropic support. Isoproterenol has been reported anecdotally to be helpful. Careful titrated use of dopamine or dobutamine is also reasonable and has the potential added advantage of improving renal perfusion.

4. Airway control is essential. Vomiting is common and endotracheal intubation should be used in any patient with a reduced level of consciousness. Supplemental oxygen should be provided when available.

5. Patients are frequently agitated, combative or seizing. Valium is effective for control and can be administered iv, endotracheally or rectally. The sedated heat stroke patient should be intubated. Nasogastric intubation to control vomiting should be done as soon as practicable.

6. Hyperkalemia is the most life threatening early clinical problem. Measurement of plasma [K] is an early priority.

7. Acute renal injury is common in exertional heat stroke. Urinary catheterization to monitor urine output and obtain urine for [Na] should be done early. The oliguric patient with a casts, pigmenturia or red cells and urine [Na] greater than 30 meq/l (before diuretics) has a high likelihood of acute renal failure. Early management of suspected acute renal failure should include assuring adequate renal perfusion and mannitol (12.5-25 grams iv).

b. Continuing Care

After cooling and hemodynamic stabilization, continuing care is supportive and is directed at the complications of heat stroke as they appear.

1. Patients with heat stroke frequently have impaired temperature regulation for several days with alternate periods of hyperthermia and hypothermia. Constant monitoring is essential and clinically significant deviations in temperature may require either cooling or warming measures. It is important to remember that changes in temperature may be due to reasons OTHER than hypothalamic instability, such as infection.

2. The effects of rhabdomyolysis that require management are renal injury due to myoglobinuria and hyperuricemia, hyperkalemia, hypocalcemia and compartment syndromes due to muscle swelling. Assurance of adequate renal perfusion and urine flow will moderate the nephrotoxic effects of myoglobin and uric acid. Hyperkalemia can be managed by kayexalate or dialysis. The hypocalcemia does not usually require treatment. Increasing tenderness or tension in a muscle compartment may represent increasing intracompartmental pressures. Direct measurement of intramuscular pressure or fasciotomy should be considered at this point. Pain and paresthesia may not signal the compartment syndrome until permanent damage has occurred.

ii. FROSBITE

Is the medical condition whereby damage is caused to skin and other tissues due to extreme cold. Frostbite is most likely to happen in body parts farthest from the heart, and those with a lot of surface area exposed to cold. Frostbite occurs when the skin and body tissues are exposed to cold temperature for a prolonged period of time. Hands, feet, noses, and ears are most likely to be affected.

Symptoms The first symptoms are a "pins and needles" sensation followed by numbness. There may be an early throbbing or aching, but later on the affected part becomes insensate (feels like a "block of wood").

Frostbitten skin is hard, pale, cold, and has no feeling. When skin has thawed out, it becomes red and painful (early frostbite). With more severe frostbite, the skin may appear white and numb (tissue has started to freeze).

Very severe frostbite may cause blisters, gangrene (blackened, dead tissue), and damage to deep structures such as tendons, muscles, nerves, and bone.

Classification of Frosbite First Degree hyperemia of involved area and edema formation

Second Degree large fluid fikled blister develop with partial thickness

Third Degree appear a small blister that contain fluid and an affected body part that is cool, numb, blue or redFourth Degree no blister or edema, the parts numb, cold and bloodloss

Types of Frosbite Superficial Mild (frostnip) induced tissue injury may produce initial pain numbness and pallor to affected area

.Deep characterized by degree of tissue freezing

First Aid Treatment1. Shelter the victim from the cold and move the victim to a warmer place. Remove any constricting jewelry and wet clothing. Look for signs of hypothermia (lowered body temperature) and treat accordingly.

2. If immediate medical help is available, it is usually best to wrap the affected areas in sterile dressings (remember to separate affected fingers and toes) and transport the victim to an emergency department for further care.

3. If immediate care is not available, re-warming first aid may be given. Immerse the affected areas in warm (never HOT) water -- or repeatedly apply warm cloths to affected ears, nose, or cheeks -- for 20 to 30 minutes. The recommended water temperature is 104 to 108 degrees Fahrenheit. Keep circulating the water to aid the warming process. Severe burning pain, swelling, and color changes may occur during warming. Warming is complete when the skin is soft and sensation returns.

4. Apply dry, sterile dressing to the frostbitten areas. Put dressings between frostbitten fingers or toes to keep them separated.

5. Move thawed areas as little as possible.

6. Re-freezing of thawed extremities can cause more severe damage. Prevent re-freezing by wrapping the thawed areas and keeping the victim warm. If re-freezing cannot be guaranteed, it may be better to delay the initial re-warming process until a warm, safe location is reached.

7. If the frostbite is extensive, give warm drinks to the victim in order to replace lost fluids.

Do Not DO NOT thaw out a frostbitten area if it cannot be kept thawed. Refreezing may make tissue damage even worse.

DO NOT use direct dry heat (such as a radiator, campfire, heating pad, or hair dryer) to thaw the frostbitten areas. Direct heat can burn the tissues that are already damaged.

DO NOT rub or massage the affected area.

DO NOT disturb blisters on frostbitten skin.

DO NOT smoke or drink alcoholic beverages during recovery as both can interfere with blood circulation

Preventions 1. Be aware of factors that can contribute to frostbite, such as extreme cold, wet clothes, high winds, and poor circulation. This can be caused by tight clothing or boots, cramped positions, fatigue, certain medications, smoking, alcohol use, or diseases that affect the blood vessels, such as diabetes.

2. Wear suitable clothing in cold temperatures and protect susceptible areas. In cold weather, wear mittens (not gloves); wind-proof, water-resistant, many-layered clothing; two pairs of socks (cotton next to skin, then wool); and a scarf and a hat that cover the ears (to avoid substantial heat loss through the scalp).

3. Before anticipated prolonged exposure to cold, don't drink alcohol or smoke, and get adequate food and rest.

4. If caught in a severe snowstorm, find shelter early or increase physical activity to maintain body warmth.

iii. HYPOTHERMIA

Hypothermia is a condition in which the core (internal) temperature is 35 C (95 F) or below as a result of exposure to cold.

Classification of Hypothermiaa.Primary / Accidental hypothermia

Occurs as a result of cold exposure.

Environmental exposure or prolonged surgical exposures are the primary cause.

b.Secondary or deliberate hypothermia

Maybe observed in patient with decrease heat production such as hypo-adrenalism, hypothyroidism, abnormal temperature regulation such as brain injuries involving the hypothalamus

Risk Factors of Hypothermia extreme age

trauma especially CNS

hypothyroidism

hypoadrenalism

parkinson s disease

multiple sclerosis

CVA

burns

malnourish/ malnutrition

sepsis

shock

trauma

vasodilatation induced by alcohol

Physiologic Effect of Hypothermiaa.Hypothermia Stage (impending hypothermia)

Core temperature - 36 C

S/ Sx

skin:pale, numb, waxy

shivering

weakness

fatigue

b.Hypothermia Stage (mild hypothermia)

Core temperature - 32- 35 C

S/ Sx

uncontrolled, intense shivering

movement less coordinated

coldness creates pain and discomfort

tachycardia

vasoconstrictio