Podcast
Questions and Answers
Which factor is primarily associated with hypertension leading to cerebrovascular accidents?
Which factor is primarily associated with hypertension leading to cerebrovascular accidents?
- Sedentary lifestyle
- Stressful and competitive environment (correct)
- Hypercholesteremia >200mg/dL
- Smoking
What initial step should be taken according to the ABC assessment in an emergency situation?
What initial step should be taken according to the ABC assessment in an emergency situation?
- Obtain vital signs
- Check patient history
- Ask about the chief complaint (correct)
- Observe surroundings for danger
Which cancer type is most directly linked to smoking?
Which cancer type is most directly linked to smoking?
- Colon Cancer
- Breast Cancer
- Lung Cancer (correct)
- Prostate Cancer
In the context of chronic obstructive pulmonary disorder, which condition is not considered a form of COPD?
In the context of chronic obstructive pulmonary disorder, which condition is not considered a form of COPD?
Which mechanism of injury is associated with the highest risk in individuals aged 15-25 years old?
Which mechanism of injury is associated with the highest risk in individuals aged 15-25 years old?
Which ESI category should a patient experiencing cardiac and pulmonary arrest fall into?
Which ESI category should a patient experiencing cardiac and pulmonary arrest fall into?
What condition is indicated by hyperkalemia?
What condition is indicated by hyperkalemia?
An unconscious patient with active seizures should be classified as which ESI level?
An unconscious patient with active seizures should be classified as which ESI level?
Which of the following patients would be classified as ESI 4 (Green)?
Which of the following patients would be classified as ESI 4 (Green)?
The primary risk associated with a burn covering more than 40% body surface area is:
The primary risk associated with a burn covering more than 40% body surface area is:
Which symptom would indicate a patient requires urgent triage (ESI 3)?
Which symptom would indicate a patient requires urgent triage (ESI 3)?
The correct evaluation for a patient with suspected dengue includes monitoring which factor?
The correct evaluation for a patient with suspected dengue includes monitoring which factor?
How would a patient with abdominal pain indicating appendicitis typically be classified?
How would a patient with abdominal pain indicating appendicitis typically be classified?
What is the primary characteristic of a patient that would categorize them as ESI 2 (Red)?
What is the primary characteristic of a patient that would categorize them as ESI 2 (Red)?
Which of the following conditions does not fall under ESI 1 urgent treatments?
Which of the following conditions does not fall under ESI 1 urgent treatments?
What is the duration of the 'Golden Hour' in patient transport for optimal outcomes?
What is the duration of the 'Golden Hour' in patient transport for optimal outcomes?
In triage systems, what is indicated by an ESI rating of 1?
In triage systems, what is indicated by an ESI rating of 1?
What is the significance of a patient having a transit time exceeding 60 minutes?
What is the significance of a patient having a transit time exceeding 60 minutes?
Which of the following is NOT an assessment category in triage?
Which of the following is NOT an assessment category in triage?
What is one of the first steps in patient stabilization in the Surgery Suites?
What is one of the first steps in patient stabilization in the Surgery Suites?
Which ESI rating indicates that a patient should be admitted to the ICU or Operating Room?
Which ESI rating indicates that a patient should be admitted to the ICU or Operating Room?
During a disaster, color-coded assessment for triage classifies patients as which of the following?
During a disaster, color-coded assessment for triage classifies patients as which of the following?
What should be administered first if a patient's systolic blood pressure is at 60?
What should be administered first if a patient's systolic blood pressure is at 60?
How is heart rate measured in a 12 lead ECG?
How is heart rate measured in a 12 lead ECG?
What does a prolonged P wave indicate in heart block?
What does a prolonged P wave indicate in heart block?
What is a characteristic of Second Degree Heart Block Type I?
What is a characteristic of Second Degree Heart Block Type I?
What is indicated when there is a blank in the reading of heartbeats in Second Degree Heart Block?
What is indicated when there is a blank in the reading of heartbeats in Second Degree Heart Block?
What is the purpose of Holter Monitoring?
What is the purpose of Holter Monitoring?
In a standard ECG, how long does one small box represent in seconds?
In a standard ECG, how long does one small box represent in seconds?
What can be inferred if the P wave is far from the QRST wave?
What can be inferred if the P wave is far from the QRST wave?
Which condition describes a normal heart rate that can occur during exercise?
Which condition describes a normal heart rate that can occur during exercise?
What is the heart rate in sinus bradyarrhythmia?
What is the heart rate in sinus bradyarrhythmia?
Which characteristic is indicative of atrial flutter?
Which characteristic is indicative of atrial flutter?
What is the primary management for an Atrial Flutter?
What is the primary management for an Atrial Flutter?
How is Pulseless Electrical Activity (PEA) characterized?
How is Pulseless Electrical Activity (PEA) characterized?
What defines polymorphic ventricular tachycardia?
What defines polymorphic ventricular tachycardia?
In the context of ventricular fibrillation, which statement is true?
In the context of ventricular fibrillation, which statement is true?
What could be a sign of hyperkalemia on an ECG?
What could be a sign of hyperkalemia on an ECG?
What is the typical heart rate for ventricular tachycardia?
What is the typical heart rate for ventricular tachycardia?
In junctional rhythm, which characteristic is noted?
In junctional rhythm, which characteristic is noted?
What does the term 'bigeminy' refer to in the context of premature ventricular contractions (PVCs)?
What does the term 'bigeminy' refer to in the context of premature ventricular contractions (PVCs)?
How does hypokalemia present on an ECG?
How does hypokalemia present on an ECG?
What advancement is commonly made with the insertion of a pacemaker?
What advancement is commonly made with the insertion of a pacemaker?
Which arrhythmia is characterized by the absence of both P waves and recognizable QRS complexes?
Which arrhythmia is characterized by the absence of both P waves and recognizable QRS complexes?
What is the hallmark of myocardial infarction on an ECG?
What is the hallmark of myocardial infarction on an ECG?
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Study Notes
Nursing Emergency and Critical Care
- Nursing Process
- Assessment: ABC (Airway, Breathing, Circulation)
- Follow the steps: Ask, Obtain, Check, Determine, Examine, Find, Gather
- Prioritization: Factors XII (12), IV Immunoglobulin (IV IG), Cryoprecipitate (Hemophilia)
- Assessment: ABC (Airway, Breathing, Circulation)
Non-Communicable Diseases (NCDs)
- Heart Disease
- Angina / Myocardial Infarction (MI)
- Sedentary individuals: Hypercholesterolemia >200 mg/dL
- Stressful and competitive lifestyles: Quick and easy, instant gratification
- Angina / Myocardial Infarction (MI)
- Neoplasm, Cancer
- Lung Cancer: Smoking
- Breast Cancer
- Prostate Cancer
- Colon Cancer: Diet
- Leukemia: Blood
- Cerebrovascular Accident (CVA)
- Ischemic and Hemorrhagic: Hypertension
- Accident
- Motor Vehicle Collision (MVC): 15-25 years old, Driving Under Influence (DUI)
- Chronic Obstructive Pulmonary Disorder (COPD)
- Bronchitis, Emphysema
Emergency Severity Index (ESI) - Triage Tool for Assessment
- ESI 1 (Blue): Seen Immediately
- Cardiac and pulmonary arrest
- Life and limb situation (major trauma)
- Unconscious / active seizure
- Shock (anaphylactic), hypoperfusion, sepsis
- Upper airway obstruction
- Respiratory failure
- Burn if airway is compromised
- ESI 2 (Red) Emergent: Seen within 15 minutes
- High-risk situation: Disoriented, distress, and danger vitals
- Stroke (BE FAST)
- Balance, blurring vision
- Facial drooping
- Arm weakness
- Speech slurring
- Time
- Sudden blindness (glaucoma, retinal detachment)
- Chest pain
- Lower airway obstruction
- Severe pain (10/10)
- Profuse bleeding
- Major head trauma
- Abnormal vital signs
- Suicidality (harming self vs ideation)
- Febrile infant (>38°C)
- Burn more than 40% body percentage
- ESI 3 (Yellow) Urgent: Seen within 30-60 minutes (Golden Hour)
- Multiple resources required for stabilization, but vitals are not in danger
- Abdominal pain (appendicitis)
- Active vomiting
- Mild asthma attack
- Allergic reaction
- Diarrhea
- Palpitations
- Fever in adults
- Mild Lower Airway Obstruction: Wheezes, pale, tachypnea/dyspnea, tachycardia
- Severe Lower Airway Obstruction: Wheezes to stridor, bradypnea to apnea, ABG respiratory acidosis, pH low (<4.5)
- ESI 4 Less Urgent (Green): Seen within 60-120 minutes
- One resource is required to stabilize the patient
- Minor trauma
- Back pain
- Headache
- Muscle pain
- Ankle injury
- Rashes
- ESI 5 Non-Urgent (White): Seen within 120-150 minutes
- Client is stable and does not require resources to be stabilized
- Sore throat
- Rabies vaccination
- Simple wound cleaning
- Sore eyes
- Prescription of medication – refill
- NGT reinsertion, Foley Catheter change
Burn Complications
- Fluid Loss: Possible cause of complication
- Hyperkalemia: Ventricular Tachycardia (T-wave peak)
Electrocardiogram (ECG)
- Equipment:
- Biphasic Defibrillator
- Cardiac Monitor: 6 seconds strip
- Portable ECG machine: 12-lead (6 or 12 seconds)
- Holter Monitoring Device: Continuous ECG monitoring
Normal Sinus Rhythm (NSR)
- To determine if regular or irregular rhythm, count the boxes between the R waves .
- Regular: Consistent number of boxes between R waves (e.g., 3 boxes)
- Irregular: Varied number of boxes between R waves (e.g., 3, 3, 4, 3)
Cardiac Arrhythmias
- Sinus Bradycardia:
- Normal for individuals engaged in physical activity (jogging, gym, etc.)
- Common in athletic individuals and those with sleep problems or taking antihistamines
- 50-60 bpm is normal for resting individuals
- If 30 bpm, it is sinus bradyarrhythmia
- Sinus Tachycardia:
- 100-120+ bpm, can reach 150-200 bpm
- Irregular
- Sinus Tachyarrhythmia if irregular
- Supraventricular Tachycardia (SVT):
- No P wave
- Lub is like a "pitik" sound
- If P or T wave is unidentified and tachycardic, considered as SVT
- 220-250 bpm
- GCS 14, chest pain, or near loss of consciousness
- Atrial Flutter:
- Numerous P waves
- No clear P waves or QRS complex
- Sawtooth appearance
- Inverted P waves in II, III, aVF
- Ventricular Tachycardia:
- Evolves from SVT
- Can be pulseless or have a pulse (different medications for each)
- P wave is destroyed, atrium is open
- Mcdonald's sign (can be treated with medication/electricity)
- Regular, broad complex tachycardia
- Monomorphic: Each QRS wave looks identical in the same lead
- Polymorphic: QRS waves vary
- Polymorphic Ventricular Tachycardia (Torsades de Pointes):
- Irregular heartbeat
- Similar to Mcdonald's sign
- Wide QRS
- Severity increases with more abnormal ECG
- Ventricular Fibrillation:
- No clear P waves or QRS complex
- Chaotic, uncoordinated electrical activity
- Amplitude decreases with longer duration, then eventually asystole
- Cardiac arrest
- Caused by electrolyte imbalances
- GCS 3
- Management: Magnesium Sulfate
- Lethal arrhythmia
- Asystole:
- Flatline
- Chest compression
- Do not shock
- Check patient and leads
- Pulseless Electrical Activity (PEA):
- No palpable pulse
- Rhythm but no pulse
- Heart beats but not strong enough
- Pulse is too weak to feel
- Premature Ventricular Contraction (PVC):
- Wide QRS
- Early beat
- Originates from the His-Purkinje region
- Not usually dangerous
- Bigeminy: Every other beat
- Atrial Fibrillation:
- Flutter but smaller
- Often associated with high blood pressure and stroke risk
- Premature Ventricular Contraction: Bigeminy (PVC every other beat)
- Ventricular Trigeminy (PVC every 3rd beat)
- Junctional Rhythm:
- Fixed T wave
- Common in patients with polypharmacy (multiple medications)
- No P wave
- Right Ventricular Hypertrophy with Bundle Branch Block (RBBB):
- Notch or M shape on the ECG
- Wider QRS (>129 ms)
- RSR in V1
- Prolonged S in V6
- M and W shape (MARROW)
- Left Ventricular Hypertrophy with Bundle Branch Block (LBBB):
- Pa W descending shape on the ECG
- No P wave
- Wide QRS
- Depressed T wave
- W and M shape
- Deep S in V1
- Prolonged R in V6 (WILLIAM)
Myocardial Ischemia, Injury, and Infarct
- Normal: No changes on ECG
- Acute: ST elevation
- Hours: ST elevation, low R wave, Q wave begins, chest pain may occur
- Day 1-2: T wave inversion, Q wave deepens
- Hallmark of MI: Pathologic T wave
- ONAM (Oxygen, Nitroglycerin, Aspirin, Morphine): Intervention for chest pain or angina
Analyzing a Rhythm Strip
- Determine the heart rate: Count the R waves
- Identify the rhythm:
- Is it Normal Sinus Rhythm (NSR)?
Patient Transport Vehicle (PTV) - Emergency Department
- Optimal: No delay
- Personnel: EMS, MD, RN, EMT, Driver, Client, Significant Other
- Equipment: EMS kit, Defibrillator, O2 tank, Stretcher, Spine board, Foldable chair
Triage
- Initial/Primary Assessment: Based on client's urgency of treatment.
- ESI 1: Resuscitation
- ESI 2: Emergent
- ESI 3: Urgent
- ESI 4: Less Urgent
- ESI 5: Non-Urgent
- Field Triage: Used during disasters, color-coded assessment
- Red: Emergency
- Yellow: Urgent
- Green: Non-Urgent
- Black: Dead
Critical Unit
- Medical care for clients with life-threatening emergencies or injuries
- Emergency department:
- Golden Hour: Less than 60 minutes for ESI 1
- Critical condition: Either up or in critical condition
- Prognosis worsens if client is in the emergency department for more than 60 minutes
- Critical Care Unit: - 60 minutes to 2 hours: Disposition either to ICU or ward - ESI 2: ICU/OR - ESI 3: Ward
- Surgery Suites:
- Critical condition: Stabilization
- Pre-operative and post-operative goals
- Systolic blood pressure below 60: Requires stabilization
- IV fluids/Inotropics
- Admitted to OR for surgery if systolic BP increased to 80/50
Third Degree Heart Block or Complete Heart Block
- Common in patients with heart failure, cardiomyopathy, cardiomegaly.
- Sharks Fin-like appearance
- 30-40 bpm
- May convert back to regular rhythm
Second Degree Heart Block (Type II or Mobitz II)
- Prolonged P wave
- Electrolyte problems, particularly with calcium
- ST segment or ST depression
- Irregular rhythm
- May lead to atrial arrhythmia
Second Degree Heart Block (Type I or Mobitz Type)
- May result from medication overdose, missed medications, or maintenance issues
- Blank spaces between beats, prolonged P wave
- Evaluate the T wave for heart block
- Wenkeback
First Degree Heart Block
- P wave is far from the QRS wave
- Atrial block to the heart's conduction
- Prolonged T wave
- Always look at T wave in heart block
Hypotonic
- Overload expands cell
- Fluid is greater than cell
Types of Hypotonic Solutions
- 0.33% NS
- 0.45% NS
- 0.225% NS
Treatment for Third Degree Heart Block
- Pacemaker
- Battery lifespan is 10-15 years
- Cheapest option is 1.8 million (assuming Philippine pesos)
- Connected to the SA node, delivering electrical impulses to the heart, providing automatic rhythm control
Understanding ECG
- R represents the beginning of measurement so if an R wave is present you don't count the box it's on.
- Small box: 0.04 seconds or 40 milliseconds
- Big box: 0.20 seconds or 200 milliseconds
- You don't count the box where the R wave is in, but you count the boxes after it.
- Heart rate = number of R waves x 10
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