Emergency Management PDF

Definition of Emergency Management Risks for ED staff, such as: Traditionally, emergency management o Exposure to infectious diseases refers to care for patients with urgent and o Physical and emotional stre...

Definition of Emergency Management Risks for ED staff, such as: Traditionally, emergency management o Exposure to infectious diseases refers to care for patients with urgent and o Physical and emotional stress critical needs. o Workplace violence and However, due to lack of access to aggression healthcare, emergency departments IV. Providing Holistic Care in a Fast-Paced (EDs) are often used for non-urgent Environment problems. Challenges in providing holistic care in a The philosophy of emergency fast-paced, technology-driven management has broadened to include environment, including: the concept that an emergency is o Prioritizing patient care in high- whatever the patient or family considers pressure situations it to be. o Managing patient flow and throughput II. Role of the Emergency Nurse o Maintaining patient-centered The emergency nurse has specialized care despite technology-driven education, training, and expertise in: demands o Assessing and identifying V. Serious Illness and Death patients' health problems in crisis The reality of encountering serious situations illness and death on a daily basis in o Establishing priorities, emergency nursing, including: monitoring, and continuously o Emotional toll on staff assessing patients who are o Importance of bereavement acutely ill and injured support and self-care o Supporting and attending to o Need for effective families communication with patients and o Supervising allied healthcare families personnel VI. Disaster Nursing o Educating patients and families Providing nursing care in disasters, within a time-limited, high- including: pressured care environment o Mass casualty incidents III. Interdisciplinary Care following natural disasters (e.g., Nursing interventions are accomplished earthquakes, tsunamis) in consultation with or under the direction o Outbreaks, epidemics, and of a physician or advanced practitioner. pandemics (e.g., exposure to Roles of nursing and medicine are pathogens) complementary in an emergency o Human-made unintentional situation. disasters (e.g., bridge collapse, Appropriate nursing and medical train crash) interventions are anticipated based on o Weapons of terror (e.g., blast, assessment data. biologic, chemical, radiologic, IV. Teamwork in Emergency Care terrorist events) Members of the ED staff work as a team to perform highly technical, hands-on Documentation of Consent and Privacy skills required to care for patients in Consent for treatment: The patient emergency situations. needs to give consent for invasive V. Types of Emergencies procedures, unless they are unconscious Examples of emergencies that require or in a critical condition and unable to emergency care include: make decisions. o Cardiac arrhythmias Monitoring and treatment o Acute coronary syndrome documentation: Monitoring of the o Acute heart failure patient's condition, treatments, and times o Pulmonary edema performed must be documented. o Stroke Patient's condition at discharge/transfer: A notation must be Issues in Emergency nursing care in a note- made on the patient's condition, taking format with explanations: response to treatment, and condition at discharge or transfer. I. Diversity of Conditions and Situations Privacy policy: Patients are provided Emergency nursing is demanding due to with a statement of the health care the variety of conditions and situations agency's privacy policy, according to that present unique challenges federal law (HIPAA). II. Legal Issues Patient privacy: Patients can request Legal issues in emergency nursing, such extra privacy by limiting access to their as: room and choosing not to receive phone o Consent and autonomy calls, mail, flowers, or certain visitors. o Confidentiality and privacy Emergency Medical Treatment and o Duty of care and responsibility Active Labor Act (EMTALA): Every ED III. Occupational Health and Safety Risks  with a Medicare provider agreement ED staff face violent situations due to must: substance use disorder, injury, or other o Perform a medical screening emergencies examination on all patients Patients and families may be emotionally arriving with an emergency volatile, leading to violent behavior medical complaint if their signs II. Patients and Family Members at Risk and symptoms could result in Patients with substance use disorder, serious injury or death if left injury, psychiatric disorders, or social untreated. situations (e.g., gang membership) o Provide treatment aimed at Patients who are under the influence of stabilizing each patient's drugs or alcohol may commit violent acts condition. Environment of the ED (e.g., long wait o Transfer patients to another times, crowded conditions) can increase facility if necessary, with consent risk of violent behavior from the patient and acceptance III. Types of Violence by the receiving facility and Physical threats primary provider. Verbal abuse (most common type of Transfer documentation: violence) Documentation of assessment and Armed patients or family members treatment must be sent with the patient, IV. Strategies for Dealing with Violence along with a note summarizing the Separate patients and families from transfer. gangs and feuding families Limiting Exposure to Health Risk Lock ED doors against entry if security is ED staff are at an increased risk of questionable exposure to communicable diseases Vigilantly monitor patients who are due to: violent or potentially violent o Bloodborne pathogens (e.g. Use non-restraint techniques (e.g., hepatitis, HIV) through talking, minimizing environmental needlesticks and other injuries stimulation) when possible o Respiratory droplets and other Use physical restraints only as needed body fluids and humanely o Invasive treatments for patients, such as suturing and wound Maintain distance from patients to avoid débridement grabbing or head-butting The risk of exposure is further Remove objects within patient reach to compounded by the increasing numbers prevent use as a tool of violence of people infected with communicable V. Special Considerations diseases, such as tuberculosis Prisoners: handcuff to bed and ensure Risk of Exposure to SARS-CoV-2 (COVID-19) safety of hospital staff and other patients The COVID-19 pandemic has highlighted Use of restraints: document reason, the risk of exposure to SARS-CoV-2, a monitor for safety, and ensure dignity of highly contagious virus patient ED staff are at risk of infection through Self-protection is a priority in case of respiratory droplets and other body fluids gunfire in the ED; security officers and Additional Risks police must gain control of the Exposure to hazardous chemicals, situation first gases, and radiation in the event of VI. Training and Resources terrorism or natural disasters Courses on safety (de-escalation and ED staff must take precautions to limit physical restraint techniques) can assist their exposure to these risks staff in preparing for various violent Transmission-Based Precautions situations Providing Holistic Care To limit the risk of exposure to airborne diseases, ED staff must: I. Trauma and Crisis o Identify patients who are Patients and families experiencing potentially infected with airborne sudden injury or illness are often diseases overwhelmed by anxiety due to lack of o Adhere strictly to transmission- time to adapt to the crisis based precautions, including: Fear of death, mutilation, immobilization, ▪ Personal Protective and assaults on personal identity and Equipment (PPE) such bodily integrity are common as masks, gowns, and II. Stages of Crisis gloves Anxiety ▪ Isolation precautions Denial ▪ Proper hand hygiene Remorse and guilt and disinfection Anger practices Grief Violence in the Emergency Department Reconciliation I. Introduction III. Initial Goal  Anxiety reduction is the primary goal for Root causes of these events revolve the patient and family, as it is a around: prerequisite to effective coping o Nurse staffing patterns IV. Safety and Precautions o Patient volume Safety is of primary importance during o Specialty availability this stressful time Solutions to patient safety issues include: Close observation and preplanning are o Ensuring optimal nurse staffing essential o Pharmacy presence Security personnel are stationed nearby o Rapid diagnostics turnaround in case of physical violence times to minimize wait time to V. Assessment diagnosis Evaluating emotional expression, degree o Fostering teamwork and support of anxiety, and cognitive functioning is by leadership essential All errors should be reported and Possible nursing diagnoses include: investigated, even if a patient was not o Anxiety or death anxiety harmed, to prevent future injury or death. associated with uncertain Family-focused Interventions potential outcomes Keep families informed: Keep families o Difficulty coping with acute updated on the patient's condition, situational crisis treatment, and location. o Family grief Family presence: Allow family members o Interrupted family process to stay with the patient, especially during o Impaired or risk for impaired resuscitation, to alleviate their anxieties family coping and build trust. VI. Explanations Family presence during resuscitation: Anxiety reduction is crucial to help Many facilities permit family presence patients and families cope with the crisis during resuscitation, which helps families effectively cope with the situation. Safety precautions are necessary to Families' positive views: Research prevent physical violence and ensure a shows that families view emergency safe environment professionals favorably when a family Assessment of emotional expression, member is resuscitated, and perceive degree of anxiety, and cognitive them as supportive and protective of the functioning helps nurses identify potential patient. nursing diagnoses and develop Family role enhancement: Allowing appropriate interventions. family presence in critical care areas Patient-Focused Interventions enhances the family's role and builds Clinicians should: trust in caregivers. o Act confidently and competently Family facilitator: A trained family to relieve anxiety and promote facilitator is essential to the success of a security family presence program, providing o Provide clear explanations that support to family members. patients can understand Additional Interventions o Use human contact and Assessment of crisis stage: reassuring words to reduce Interventions are based on the panic and fear assessment of the family's stage of crisis, Treat unconscious patients as if they are which includes factors such as emotional conscious: distress, anxiety, and uncertainty. o Touch them I. Emotional Responses o Call them by name Anxiety: Recognize and talk about o Provide explanations of every feelings of anxiety procedure performed Denial: Avoid prolonged denial, but As the patient regains consciousness, acknowledge reality orient them by: II. Expressions of Emotions o Stating their name Remorse and Guilt: Verbalize feelings o Date to cope with regret and self-blame o Location Anger: Express anger to manage o Repeating this information as anxiety and fear, directed towards the needed in a reassuring way patient, physician, nurse, or admitting Patient Safety personnel Ensuring patient safety is a major focus Grief: Support family members in in clinical practice settings working through grief and loss Common sentinel events (unanticipated Key Nursing Interventions events that result in patient harm) in the Help family members identify and ED include: verbalize their feelings o Delays to care Allow expression of emotions (anger, o Medication errors remorse, grief)  Support coping mechanisms (e.g., ENA (2020a) refers to the Emergency crying, expressing loss) Nurses Association. Provide reassurance that it's normal and Schmidt & Haglund (2017) refers to a acceptable to feel emotions study on compassion fatigue. Additional Resources CISM is an abbreviation for Critical Hospital chaplain: Support family Incident Stress Management. members in working through grief and Principles of Emergency Care loss Emergency Care is Time-Sensitive: Social services staff: Assist families in Care must be rendered without delay, as coping with the crisis patients may have life-threatening Care for Emergency Personnel conditions that require immediate Key points: attention. o Focus on ED staff well-being, Triage: The first principle of emergency especially after stressful events care, triage involves sorting patients (ENA, 2020a) based on the severity of their condition, o Events can range from local prioritizing those who need immediate trauma to natural disasters or attention. mass casualty incidents Triage Definition and Purpose o Staff members may respond Triage comes from the French word differently to stressful events "trier", meaning "to sort" Explanations: ED staff may experience Used to sort patients into groups based compassion fatigue due to continuous on severity of health problems and exposure to suffering and injury, which urgency of treatment can lead to energy depletion (Schmidt & Goal: rapid assessment and decision- Haglund, 2017). Fatigue occurs when the making, preferably under 5 minutes affected staff members cannot replenish Triage Systems energy stores. Basic system: emergent, urgent, and Support Systems non-urgent categories Key points: Comprehensive system: 5-level triage o ED leadership should be aware severity rating system (e.g. Emergency of staff coping patterns and Severity Index (ESI), Canadian Triage support systems and Acuity Scale (CTAS)) o Identify staff members' health Levels of Triage problems, including addiction ESI: 5 levels, from level 1 (most urgent) o Provide nonjudgmental to level 5 (least urgent) counseling to promote healthy CTAS: 5 levels, including time staff parameters for reassessment Explanations: ED leadership should be Triage Concepts aware of the impact of workplace stress Triage bypass: moves patient directly to on staff and provide support systems to a bed if open beds are available help them cope. This includes identifying Team triage (or provider in triage): nurse health problems, including addiction, and works with physician or provider in the providing nonjudgmental counseling. triage area Critical Incident Stress Management (CISM) Both concepts decrease wait time and Key points: improve flow in the ED o CISM useful for reviewing Triage Process individual and group Triage nurse assesses patient and performance after serious events classifies illness or injury o Consists of three steps: Follows protocols for laboratory or x-ray defusing, debriefing, and follow- studies up Collects additional crucial baseline data, Explanations: CISM helps staff process including: their experiences and emotions after a o Full vital signs critical incident. The three steps are: o History of current event and past o Defusing: Immediate session medical history after the incident to discuss o Neurologic assessment findings feelings and reassure staff that o Weight negative reactions are normal. o Allergies (especially to latex and o Debriefing: Session 1-10 days medications) after the incident to discuss o Intimate partner violence feelings and reassurance that screening negative reactions will diminish o Necessary diagnostic data over time. Importance of Asking Questions o Follow-up: Ongoing individual Asking questions is key to appropriate or group counseling and therapy triage decisions for those who require further Minimum information to be obtained from support. patient or person accompanying patient: Note:  o Thorough summary of patient's Circulation: evaluate and restore cardiac condition and history output, control hemorrhage, prevent and o Any necessary diagnostic data treat shock I. Definition and Purpose of Triage Disability: determine neurologic disability Triage is a process that involves by assessing neurologic function using assessing patients' conditions and Glasgow Coma Scale (GCS) and motor prioritizing their care based on the and sensory evaluation of spine severity of their injuries or illnesses. Exposure: undress patient quickly but II. Components of Triage gently to assess wounds or areas of Collection of initial vital signs and medical injury history IV. Neurologic Assessment Providing basic first aid (e.g. application Quick neurologic assessment using of ice, bleeding control, wound care) AVPU mnemonic: Initiating protocol-based prescriptions o A - Alert: is patient alert and (e.g. x-rays, antipyretic or mild analgesic responsive? agents, ECG or urinalysis) o V - Verbal: does patient respond Removing sutures to verbal stimuli? III. Roles and Responsibilities of the Triage o P - Pain: does patient respond Nurse only to painful stimuli? Assessing patients' conditions and o U - Unresponsive: is patient prioritizing their care unresponsive to all stimuli? Monitoring the waiting area and Secondary Survey maintaining a safe environment Complete health history, including Reassessing patients who are waiting current event Initial liaison to families of patients Head-to-toe assessment, reassessment IV. ED Triage Protocols of airway, breathing, and vital signs Routine ED triage protocols prioritize Diagnostic and laboratory testing care based on the severity of patients' Insertion or application of monitoring conditions devices Scarce resources are directed to the Splinting of suspected fractures most critically ill patients Cleansing, closure, and dressing of V. Field Triage (Disaster Triage) wounds Used in disasters and mass casualty Performance of other necessary incidents interventions Scarce resources are used to benefit the Patient Management most people possible Focus on comfort and emotional support Triaged decisions are made differently for patient and family due to limited resources Effective pain management: VI. Key Takeaways o Rapid-acting agents for minimal Triage is a critical process in emergency sedation medicine that prioritizes patient care o Moderate sedation for short based on severity of condition procedures Routine ED triage protocols prioritize Monitoring during procedures care based on severity of condition, while o Rapid awakening after field triage protocols prioritize care based procedure on limited resources and the need to Family Support benefit the most people possible Family crisis intervention services Emergency Care Priorities available I. Stabilization and Transfer Chaplain and social worker may assist Prioritize stabilization and transfer of with interventions patient with urgent or higher triage Every family needs attention and category support, even if patient's condition is not Focus on stabilizing life-threatening emergent conditions and transferring to appropriate Upper Airway Obstruction setting (ICU, OR, GCU) II. Primary Survey/Secondary Survey 1. Definition: Acute upper airway Approach obstruction is a life-threatening medical Primary survey: focus on stabilizing life- emergency. threatening conditions 2. Pathophysiology: Secondary survey: ongoing definitive o Partial obstruction can lead to treatment of underlying problem progressive hypoxia, III. A-B-C-D-E Method hypercarbia, and respiratory and Airway: establish a patent airway cardiac arrest. Breathing: provide adequate ventilation, o Complete obstruction can lead to employ resuscitation measures when permanent brain injury or death necessary within 3-5 minutes due to hypoxia.  o Oxygen saturation of the blood Ask the patient if they are choking and decreases rapidly, and oxygen require help deficit occurs in the brain, Inspect the oropharynx if the patient is causing unconsciousness and unconscious death. Consider additional diagnostic tests: 3. Causes: o X-rays o Aspiration of foreign bodies o Laryngoscopy o Anaphylaxis o Bronchoscopy o Viral or bacterial infection Key Findings o Trauma Identification of the offending object in the o Inhalation or chemical burns airway o Sedative and hypnotic Presence of respiratory distress or medications difficulty breathing o Diseases affecting motor Patient's level of consciousness (e.g. coordination (e.g., Parkinson's conscious, unconscious) disease) Diagnostic Implications o Mental dysfunction (e.g., Early identification of the object can aid in dementia, intellectual disability) prompt removal and treatment of the o Atrophy of the posterior pharynx patient's airway obstruction with age Additional diagnostic tests may be 4. Risk Factors: necessary to confirm the presence and o Older adult patients, especially location of the object those in extended care facilities Oxygen supplementation may be o Aspiration of a bolus of meat is indicated to support respiratory function the most common cause of Airway Obstruction Management airway obstruction in adults Key Points: o Peritonsillar abscesses, Suspect partial obstruction if patient can epiglottitis, and other acute breathe and cough spontaneously infectious processes of the posterior pharynx can also result Encourage patient to cough forcefully in airway obstruction and persist with spontaneous breathing efforts 5. Common Causes: o Allergic reaction (causing Look for signs of complete obstruction laryngospasm) (weak cough, high-pitched noise, o Infection increased respiratory difficulty, cyanosis) o Angioedema If signs of complete obstruction, manage Clinical Manifestations of Foreign-Body Airway as if there were complete airway Obstruction obstruction Key Points: Steps: Inability to Speak, Breathe, or Cough: 1. Remove obstruction Patient is unable to speak, breathe, or 2. Initiate rescue breathing cough due to the obstruction. 3. If no pulse, institute cardiac compressions Universal Distress Signal: Patient may 4. Provide oxygen to brain, heart, and other clutch their neck between their thumb and fingers (a universal distress signal). vital organs until definitive medical treatment Common Signs and Symptoms: Establishing an Airway o Choking o Apprehensive appearance May require repositioning the patient's head to prevent tongue obstruction or o Refusing to lie flat other maneuvers o Inspiratory and expiratory stridor o Labored breathing Cervical spine must be protected from o Use of accessory muscles injury (suprasternal and intercostal Assess breathing by observing chest retraction) movement, listening and feeling for air o Flaring nostrils movement o Increasing anxiety I. Oropharyngeal Airway o Restlessness A semicircular tube or tubelike device o Confusion inserted over the back of the tongue into Late Signs: the lower posterior pharynx o Cyanosis (bluish discoloration of Prevents tongue from falling back and the skin) obstructing the airway o Loss of consciousness (due to Allows for suctioning of secretions severe hypoxia) II. Nasopharyngeal Airway Assessment and Diagnostic Findings Provides the same airway access as Patient Information oropharyngeal airway, but inserted Patient with a foreign object occluding through the nares the airway Allows for spontaneous breathing Assessment Contraindication  Nasopharyngeal airway should not be Key Points: used in cases of potential facial trauma or Definition: Opening of the cricothyroid basal skull fracture due to risk of brain membrane to establish an airway entry Indications: Emergency situations Nursing Diagnoses where endotracheal intubation is not Impaired airway clearance due to possible or contraindicated obstruction by tongue, object, or fluids o Examples: Impaired breathing due to airway ▪ Airway obstruction due obstruction or injury to maxillofacial trauma, Endotracheal Intubation Summary cervical spine injuries, I. Purpose laryngospasm, laryngeal Establish and maintain airway in patients edema (after allergic with respiratory insufficiency or hypoxia reaction or extubation), II. Indications hemorrhage into neck Establish airway for patients who cannot tissue, or obstruction of be adequately ventilated with a the larynx nasopharyngeal or oropharyngeal airway Procedure: Used in emergency Bypass upper airway obstruction situations Prevent aspiration Replacement: Replaced with formal Permit connection to resuscitation bag or tracheostomy when patient can tolerate it mechanical ventilator Maintaining Ventilation Facilitate removal of tracheobronchial Key Points: secretions 1. Check for equal bilateral breath III. Who Performs Endotracheal Intubation sounds: After ensuring the airway is Physicians unobstructed, the nurse must check for Nurse anesthetists equal breath sounds to ensure adequate ventilation. Respiratory therapists 2. Prevent hypoxia and hypercapnia: Flight nurses Satisfactory management of ventilation Nurse practitioners can prevent these complications. Emergency nurse assists with intubation 3. Monitor for absent or diminished IV. Rapid Sequence Intubation (RSI) breath sounds: The nurse should Indicated in emergency situations similar quickly assess for absent or diminished to those in the operating room breath sounds, open chest wounds, and Medications used: difficulty delivering artificial breaths. o Sedative 4. Monitor pulse oximetry, capnography, o Analgesic and arterial blood gases: If the patient o Neuromuscular blockade requires airway or ventilatory assistance, Intubation with King Tube or Laryngeal Mask monitor these vital signs to ensure Airway (LMA) adequate ventilation. Key Points: 5. Assess for tension pneumothorax: A 1. King Tube: Rapidly provides pharyngeal tension pneumothorax can mimic ventilation when a patient cannot be hypovolemia, so ventilatory assessment intubated in the field. precedes assessment for hemorrhage. 2. Insertion: The tube is inserted into the 6. Manage pneumothorax and sucking trachea, with two balloons that surround wound: A pneumothorax (simple or the tube. tension) or sucking chest wound is 3. Balloon Function: One balloon managed with a chest tube and occlusion occludes the oropharynx, allowing of the sucking wound to relieve ventilation by forcing air through the increasing positive intrathoracic pressure larynx. The smaller balloon occludes the and maintain adequate ventilation. esophagus at a site distal to the glottis. 4. Verification: Breath sounds are HEMORRHAGE auscultated after balloon inflation to I. Definition and Causes of Hemorrhage ensure the oropharyngeal balloon does Definition: Hemorrhage is a main cause not obstruct the glottis. of shock, resulting in the reduction of 5. Variants: Some King Tubes have a circulating blood volume. gastric tube for suction. Causes: 6. Laryngeal Mask Airway (LMA): An o Minor bleeding (usually venous) interim airway device used when can stop spontaneously, unless establishing an airway is difficult. the patient has a bleeding 7. LMA Function: Provides a "mask" in the disorder or has been taking subglottic airway with a cuff inflated anticoagulant agents. within the esophagus, allowing easy o Internal hemorrhage can hide in insertion and rapid airway control. anatomic spaces and 8. Additional Features: Some LMAs compartments, resulting in shock permit removal of secretions from the without external evidence of esophagus. hemorrhage. Cricothyroidotomy II. Assessment of Shock  Signs and symptoms of shock: Most bleeding can be stopped or o Cool, moist skin (resulting from controlled by direct pressure poor peripheral perfusion) Firm pressure dressing applied to injured o Decreasing blood pressure area o Increasing heart rate Elevated injured part to stop venous and o Delayed capillary refill capillary bleeding (if possible) o Decreasing urine volume III. Tourniquet Application III. Goals of Emergency Management Applied to extremity when external Control the bleeding hemorrhage cannot be controlled in any Maintain adequate circulating blood other way volume for tissue oxygenation Just proximal to wound, tied tightly to Prevent shock control arterial blood flow IV. Risks and Complications Labeled with date and time of application Patients who hemorrhage are at risk for Remains in place until surgery or until cardiac arrest caused by hypovolemia patient is in operating room for traumatic with secondary anoxia amputation V. Nursing Interventions IV. Documentation Carried out collaboratively with other Time of tourniquet application and members of the emergency healthcare removal documented team V. Summary Management Direct pressure is the primary method of Fluid replacement is crucial in managing controlling external hemorrhage hemorrhaging patients to maintain circulation and Tourniquet application is used as a last prevent shock resort when direct pressure is ineffective II. Fluid Replacement Tourniquet placement has been shown to Two large-gauge IV catheters are reduce mortality in military personnel with inserted in an uninjured extremity for fluid battle-associated trauma, but may and blood replacement occasionally lead to amputation or Blood samples are obtained for analysis, fasciotomy. typing, and cross-matching Control of Internal Hemorrhage Replacement fluids include: I. Signs and Symptoms of Internal o Isotonic electrolyte solutions Hemorrhage (e.g., lactated Ringer's, normal Tachycardia saline) Falling blood pressure o Colloids Thirst o Blood component therapy Apprehension III. Blood Component Therapy Cool and moist skin Packed red blood cells are infused for Delayed capillary refill massive blood loss II. Treatment May necessitate transfusion of other Packed red blood cells, plasma, and blood components: platelets administered rapidly o Platelets Patient prepared for more definitive o Clotting factors (e.g., ENA) treatment (e.g. surgery, pharmacologic Infusion rate is determined by: therapy) o Severity of blood loss Arterial blood gas specimens obtained to o Clinical evidence of hypovolemia evaluate: IV. Administration of Blood Replacement o Pulmonary function Therapy o Tissue perfusion Administer via warmer, when possible, to o Baseline hemodynamic prevent core cooling effect and cardiac parameters arrest Patient maintained in supine position and Large amounts of refrigerated blood may monitored closely until: lead to coagulopathy o Hemodynamic parameters V. Conclusion improve Fluid replacement and blood component o Transported to operating room or therapy are essential in managing intensive care hemorrhaging patients to prevent shock Hypovolemic Shock and maintain circulation. Definition: Hypovolemic shock is a condition Control of External Hemorrhage characterized by a loss of effective circulating I. Assessment blood volume, leading to inadequate organ and Rapid physical assessment performed tissue perfusion, and ultimately, cellular metabolic while cutting away clothing to identify derangements. area of hemorrhage Causes: Direct, firm pressure applied over Most common cause of shock bleeding area or involved artery proximal Underlying cause must be determined to wound (hypovolemic, cardiogenic, neurogenic, II. Direct Pressure anaphylactic, or septic) Key Points:  Shock should be anticipated by o Vascularity of tissues immediately assessing all people who 2. Procedure: are injured in an emergency situation o Wound is sutured or stapled by Inadequate organ and tissue perfusion the emergency provider follows loss of effective circulating blood o Patient receives local anesthesia volume or moderate sedation (see Cellular metabolic derangements occur Chapter 15) as a result of inadequate perfusion 3. Wound Closure Steps: WOUND o Bring subcutaneous fat together I. Types of Wounds loosely with a few sutures to Minor tears to severe crushing injuries close off dead space II. Main Goal of Treatment o Close subcuticular layer Restore physical integrity and function of o Close epidermis injured tissue 4. Suturing Techniques: Minimize scarring and prevent infection o Sutures placed near wound edge III. Documentation o Wound edges leveled carefully Precise descriptions and correct to promote optimal healing terminology 5. Alternative Closure Methods: o Sterile strips of reinforced Essential for future forensic evidence microporous tape Photographs helpful for accurate o Bonding agent (skin glue) for depiction of wound clean, superficial wounds IV. Determining Wound Occurrence Delayed Primary Closure When and how the wound occurred Indications: Treatment delay increases infection risk Tissue loss Aseptic technique used to inspect wound High risk of infection V. Evaluation Procedure: Extent of damage to underlying Apply a thin layer of gauze to ensure structures or presence of foreign body drainage and prevent pooling of exudate Sensory, motor, and vascular function Cover with an occlusive dressing evaluated for changes indicating Splint the wound in a functional position complications to prevent motion and contracture Wound Care and Management Suturing: I. Wound Preparation If no signs of suppuration (purulent Hair around the wound may be clipped drainage), the wound may be sutured only as directed if necessary under local anesthesia Area around the wound is cleansed with Antibiotic prophylaxis: normal saline solution or polymer agent Depends on factors such as injury (e.g., Shur-Clens) mechanism, wound age, and risk of Antibacterial agent povidone-iodine contamination should not be used deeply without Given as prescribed to prevent infection thorough rinsing due to tissue damage Immobilization and elevation: risk Site is immobilized and elevated to limit II. Local Anesthesia accumulation of fluid in the interstitial If indicated, area is infiltrated with local space of the wound intradermal anesthetic through wound Tetanus prophylaxis: margins or regional block Given as prescribed based on wound Patients with soft tissue injuries typically condition and patient's immunization experience localized pain at the site of status injury Booster given if last tetanus booster was III. Wound Treatment > 5 years ago or immunization status is Wound is irrigated gently and copiously unknown with sterile isotonic saline solution to Patient Education: remove surface dirt and debris Educated on signs and symptoms of Devitalized tissue and foreign matter are infection removed to promote healing and prevent Instructed to contact primary provider or infection clinic if: Small bleeding vessels are clamped, o Sudden or persistent pain tied, or cauterized o Fever or chills Nonadherent dressing is applied to o Bleeding protect the wound and serve as a splint o Rapid swelling and reminder to the patient that the area o Foul odor is injured o Drainage or redness surrounding Primary Closure of Wounds the wound Key Points: TRAUMA 1. Indications for Primary Closure: Unintentional or intentional wound or injury o Nature of the wound inflicted on the body from a mechanism against o Time since injury which the body cannot protect itself. o Degree of contamination  Leading cause of death: Mortality in patients with multiple trauma o Children: #1 is related to the severity of the injuries, o Adults younger than 44 years: #1 the number of systems and organs o Adults older than 44 years: involved, and the severity of each injury increasing incidence alone and in combination. SUD (Substance Use Disorder) often III. Single-System Trauma implicated as a factor: Patients with single-system trauma can o In both blunt and penetrating also have life-threatening or very severe trauma traumatic injuries. Trauma Care and Forensic Evidence IV. Physiological Response to Trauma I. Importance of Documentation Immediately after injury from major Meticulous documentation is essential in trauma, including multiple trauma or assessing and managing patients with severe single-system trauma, the body is traumatic injuries, especially in cases of hypermetabolic and severely stressed. suspected criminal activity. V. Complications of Trauma Documentation includes descriptions of Major trauma can cause hypothermia, wounds, mechanism of injury, time of acidosis, and coagulopathy, sometimes events, and collection of evidence. referred to as the "triad of death" because II. Handling and Documenting Evidence each of these factors is associated with Nurses must be careful when handling increased mortality. and documenting evidence to ensure its Management of Trauma integrity and validity. Summary: In trauma cases, external evidence Clothing should be placed in individual may be sparse or absent, and multiple injuries paper bags to prevent moisture from should be assumed to have a spinal cord injury promoting mold and mildew formation, until proven otherwise. The least significant- which can destroy evidence. appearing injury may be the most lethal. Valuables should be inventoried and Key Points: either placed in the hospital safe or External evidence of trauma may be clearly documented to which family sparse or absent member they were given. Assume spinal cord injury in patients with III. Chain of Custody multiple trauma A formal chain of custody must be Least significant-appearing injury may be maintained for evidence to be valid and the most lethal useful for legal purposes. Example: Pelvic fracture may cause Evidence cannot be left unattended in the rapid and massive hemorrhage, while an room; each item should be labeled and obvious arm amputation may have the transfer of custody to a police officer already stopped bleeding or other authorized person should be Example: Pelvic fracture may cause documented. rapid and massive hemorrhage, while an IV. Reporting Deaths and Suspected Suicide obvious arm amputation may have or Homicide already stopped bleeding All deaths of patients who experienced Trauma Alert and Trauma Team trauma should be reported to the medical examiner. Definition: A trauma alert is typically If suicide or homicide is suspected, the activated for patients with major trauma medical examiner should examine the who present to trauma centers. body on site or have it moved to the Criteria: The criteria for activating a coroner's office for autopsy. trauma alert vary depending on the V. Additional Tips individual institution. Photographs of wounds or clothing are Trauma Team: The trauma team is essential and should include a reference composed of designated members, ruler in one photo and another without including a trauma surgeon, trauma ruler. emergency nurse, x-ray technician, Documentation should include any nursing assistant, advanced practice statements made by the patient in their nurse, and chaplain. own words and surrounded by quotation Trauma Emergency Nurse marks. Responsibilities: Assess and monitor A clear chain of evidence is essential to the patient, maintain airway and IV assist the judicial process if the patient's access, administer prescribed case is reviewed in a court of law in the medications, collect laboratory future. specimens, and document activities and MULTIPLE TRAUMA patient responses. I. Definition of Multiple Trauma Hypothermia Management: Implement Multiple trauma is caused by a single interventions to mitigate the effects of catastrophic event that causes life- hypothermia, such as keeping the threatening injuries to at least two distinct ambient temperature higher than normal, organs or organ systems. removing wet clothing, applying warm II. Mortality Factors blankets, and warming IV fluids.  Fluid Management: Use lactated Assess the chest and other body Ringer's solution as the preferred IV systems for injuries that commonly crystalloid solution to manage accompany intraabdominal injury. hypovolemia, while judiciously managing o Note: This is a thorough fluid administration to avoid diluting assessment to identify potential clotting factors and causing associated injuries. coagulopathy. Monitoring: Continuously monitor the Internal Hemorrhage patient's hemodynamic status, temperature, and ambient environment Hemorrhage often accompanies to reduce the risks of hypothermia, abdominal injury, especially if liver or acidosis, and coagulopathy. spleen is traumatized Patient is continuously assessed for Intra-Abdominal Injuries signs and symptoms of external and internal bleeding 1. Penetrating Injuries: Serious injuries Physical exam: inspect front, flanks, and that require surgery, often resulting in back for discoloration, asymmetry, injury to hollow organs, especially the abrasions, and contusions small bowel. Abdominal CT scans and ultrasounds o Examples: gunshot wounds, (FAST examination) are used to assess stab wounds. abdominal contents and retroperitoneal 2. Penetrating Trauma: High-velocity examination missiles (bullets) cause extensive tissue Opioids are used to manage pain during damage, requiring surgical exploration. resuscitation period o Low-velocity missiles may be managed non-operatively (ENA, ENVIRONMENTAL EMERGENCIES 2020a). 3. Blunt Trauma: Common causes include Heat-related illnesses: Can occur due motor vehicle crashes, falls, blows, or to high temperatures, including heat explosions. stroke, frostbite, and hypothermia. o Associated with extra-abdominal Non-fatal drowning: Can occur due to injuries to the chest, head, or water-related incidents. extremities. Drowning: Can be fatal if not addressed 4. Blunt Trauma Challenges: Difficult to promptly. detect injuries, with higher incidence of delayed and trauma-related complications. HEAT-INDUCED ILLNESS o Especially true for blunt injuries involving the liver, kidneys, I. Definition and Causes of Heat-Induced spleen, or blood vessels, which Illnesses can lead to massive blood loss into the peritoneal cavity. Heat-induced illnesses are a range of conditions that can vary from mild to life- Assessment and Diagnostic Findings threatening emergencies. Heat stroke is the most serious form, During the secondary survey, inspect the caused by failure of the body's heat- abdomen for obvious signs of injury, regulating mechanisms, usually due to including penetrating injuries, bruises, prolonged exposure to temperatures and abrasions. above 39.2°C (102.5°F) or a heat index o Note: This is part of the thorough above 35°C (95°F). assessment to identify potential injuries. II. Types of Heat-Induced Illnesses Auscultate bowel sounds to provide baseline data for future comparison. Heat stroke: a medical emergency o Note: Absence of bowel sounds caused by failure to maintain cardiac may indicate intraperitoneal output in the face of high body involvement, but stress can also temperatures and dehydration. affect bowel sounds. Exertional heat stroke: caused by Continue assessing the abdomen for strenuous physical activity in a hot signs of peritoneal irritation, including: environment. o Progressive abdominal Heat exhaustion: a less severe distention condition caused by inadequate heat o Involuntary guarding loss. o Tenderness Heat illness or heat cramps: a mild o Pain condition caused by loss of electrolytes o Muscular rigidity during strenuous physical activity in a hot o Rebound tenderness environment. o Changes in bowel sounds o Hypotension and signs of shock III. Risk Factors for Heat-Induced Illnesses may also be present. o Note: These signs indicate potential intraabdominal injury. People not acclimatized to heat Older adults  Young children o Gooseflesh Those with chronic and debilitating o Orthostasis diseases Cardinal manifestations of heat Those taking certain medications illness: Muscle cramps (shoulders, People with mental illness abdomen, lower extremities), profound diaphoresis, and profound thirst. IV. Mortality Rates Management of Heat Stroke Older adults, young children, people with mental illness, and those with chronic I. Goal diseases have the highest rates of mortality. Reduce high body temperature as quickly as possible to prevent mortality Gerontologic Considerations and morbidity Older adults are more susceptible to II. Stabilization heat-related deaths: Their circulatory systems are less able to compensate for Establish IV access for fluid heat stress. administration Decreased sweating ability: Older Focus on stabilizing oxygenation using adults have a decreased ability to CABs (Circulation, Airway, and perspire, which makes it harder for their Breathing) of basic life support body to regulate temperature. Vascular dysfunction: Older adults also III. Cooling have decreased ability to vasodilate and vasoconstrict, making it harder for blood Remove patient's clothing vessels to regulate blood flow and Cool core temperature to 39°C (102°F) temperature. as rapidly as possible (preferably within 1 Less subcutaneous tissue: Older hour) adults have less fatty tissue under their Use methods such as cool sheets and skin, which makes it harder for their body towels, ice packs, colling blankets, or to cool down. immersion in cold water bath Decreased thirst mechanism: Older Monitor temperature constantly with a adults may not feel thirsty when they thermistor should, which can lead to dehydration. Stop cooling at 38°C to avoid iatrogenic Impaired urine concentration: Older hypothermia adults may have difficulty concentrating their urine, which can lead to dehydration. IV. Supportive Care Inadequate fluid intake: Many older adults do not drink enough fluid due to Provide 100% oxygen to meet tissue fear of incontinence. needs exaggerated by hypermetabolic Fear of crime: Older adults may be condition hesitant to open windows or use fans due Consider endotracheal intubation and to fear of crime, even if their residence mechanical ventilation if lacks air conditioning. cardiopulmonary systems fail Administer IV infusion therapy with Heat Stroke normal saline or lactated Ringer's solution to replace fluid losses and maintain circulation Causes: Thermal injury at cellular level, coagulopathies, and damage to heart, Monitor urine output and blood liver, and kidneys due to exposure to specimens for serial testing to detect elevated ambient temperature or bleeding disorders and thermal hypoxic excessive exercise during extreme heat. injury Symptoms: Profound CNS dysfunction Provide supportive care such as dialysis (confusion, delirium, bizarre behavior, for AKI, anticonvulsant medication for coma, seizures), elevated body seizures, potassium for hypokalemia, temperature (40.6°C or higher), hot dry and sodium bicarbonate for metabolic skin, anhidrosis (absence of sweating), acidosis tachypnea, hypotension, and Prescribe benzodiazepines such as tachycardia. diazepam to suppress seizure activity Distinguishing features from Heat and phenothiazines such as Exhaustion: chlorpromazine to suppress shivering o High body temperatures o No diaphoresis (sweating) V. Patients with Heat Exhaustion or Heat o No gooseflesh Illness o Coma or seizures Heat Exhaustion symptoms: Manage patients with heat exhaustion or o Headaches heat illness less aggressively o Anxiety Patients with heat exhaustion should lie o Syncope supine in a cool environment and receive o Profuse diaphoresis (sweating) IV fluids or oral fluids if tolerated  Patients with heat illness should receive III. Pain Management and Protection oral sodium supplements and oral electrolyte solutions Analgesic for pain is given as prescribed Educate patients who have experienced Avoid handling or massaging the affected a heat-induced illness on how to prevent body part another heat-induced illness Protect the part from further injury, elevate to control swelling FROST BITE Apply sterile gauze or cotton between affected fingers or toes Frostbite is a condition that occurs when body parts are exposed to freezing temperatures, IV. Post-Rewarming Care causing the freezing of intracellular fluid and fluids in intercellular spaces, leading to cellular Monitor for concomitant injuries, such as and vascular damage. soft tissue injury, dehydration, and alcohol intoxication Symptoms: Frostbite can range from first degree Correct problems such as hyperkalemia (redness and erythema) to fourth degree (full- and hypovolemia depth tissue destruction), affecting body parts Use aseptic technique during dressing such as feet, hands, nose, and ears. changes and provide tetanus prophylaxis as indicated Causes: Frostbite occurs when body parts are Prescribe NSAIDs for anti-inflammatory exposed to freezing temperatures, leading to effects and pain control venous stasis and thrombosis. V. Additional Measures Treatment: Whirlpool bath for circulation and Medication: None specific, but pain débridement of necrotic tissue management with analgesics such as Escharotomy to prevent further tissue acetaminophen or ibuprofen may be damage and promote circulation necessary. Fasciotomy to treat compartment Warming: Gradual warming of the syndrome affected area is recommended to prevent Encourage hourly active motion of further damage. affected digits to promote restoration of Monitoring: Monitor for signs of function and prevent contractures infection, gangrene, or tissue necrosis. Surgery: In severe cases, surgical VI. Discharge Instructions debridement may be necessary to remove damaged tissue. Avoid tobacco, alcohol, and caffeine due to vasoconstrictive effects Assessment and Diagnostic Findings Encourage patient to follow up with healthcare provider for follow-up care Frozen Extremity: A frozen extremity may be hard, cold, and insensitive to Medications Given: touch, appearing white or mottled blue- white. History: Patient history should include Analgesic for pain (prescribed) environmental temperature, duration of Nonsteroidal anti-inflammatory drugs exposure, clothing worn, humidity, and (NSAIDs) for anti-inflammatory effects presence of wet conditions. and pain control Injury Extent: The extent of injury from Tetanus prophylaxis (if indicated) exposure to cold is not always initially known. HYPOTHERMIA Key Points: Cold extremity assessment requires considering environmental I. Definition and Causes factors and patient history. Hypothermia is a condition where the I. Management of Frostbite core body temperature is 35°C (95°F) or less. Goal: Restore normal body temperature Causes: exposure to cold, inability to Remove constrictive clothing and maintain body temperature, urban jewelry, wet clothing, and allow patient to hypothermia, and concurrent medical rest conditions. II. Rewarming II. Risk Factors Controlled yet rapid rewarming is High-risk groups: older adults, infants, instituted people with concurrent illnesses, and Frozen extremities are placed in a 37°C those who are homeless. to 40°C circulating bath for 30-40 minutes Factors that increase susceptibility: Repeat until circulation is restored alcohol ingestion, fatigue, sleep  deprivation, and certain medications Monitoring (e.g., phenothiazines). Medical conditions that decrease Prioritize CABs of basic life support ability to shiver: hypothyroidism, spinal Frequent evaluation of vital signs, CVP, cord injury. urine output, blood chemistry, and chest x-rays III. Effects of Wet Clothing and Immersion Monitor core body temperature with esophageal, bladder, or rectal thermistor Wet clothing accelerates heat loss. Continuous ECG monitoring to prevent Immersion in cold water increases heat cold-induced myocardial irritability loss by 25%. Rewarming IV. Treatment Considerations Active internal rewarming for moderate to Treatment priority: hypothermia takes severe hypothermia (less than 28°C to precedence over frostbite. 32.2°C) Considerations: victims of trauma may o Methods: cardiopulmonary be at risk for hypothermia due to bypass, warm fluid treatment with cold fluids, unwarmed administration, warmed oxygen, and exposure during humidified oxygen by ventilator, examination. and warmed peritoneal lavage Passive or active external rewarming for Assessment and Diagnostic Findings mild hypothermia (32.2°C to 35°C) o Passive external rewarming: use over-the-bed heaters to increase Physiologic Changes: Hypothermia blood flow to extremities leads to deterioration in all organ o Active external rewarming: use systems, causing apathy, poor judgment, forced-air warming blankets (but ataxia, dysarthria, drowsiness, be cautious of extremity burns) pulmonary edema, acid-base abnormalities, coagulopathy, and coma. o Short explanation: Hypothermia NEAR DROWNING causes a range of physiological changes that affect various Definition: Survival for at least 24 hours organ systems, leading to a after submersion that caused a range of symptoms from mild to respiratory arrest severe. Consequences: Hypoxemia, most Body's Self-Warming common complication Mechanisms: Shivering is suppressed Risk Factors: Children under 5 and over at a temperature of less than 32.2°C 85, rip currents, pool drownings, lack of (90°F), as the body's natural warming swimming lessons, and poor supervision mechanisms become ineffective. Prevention: Avoiding rip currents, o Short explanation: As the body's surrounding pool with fencing and gate, core temperature drops below providing swimming lessons, and 90°F, shivering becomes less supervision near water effective in generating heat, Drowning Events: Pools, lakes, and making it harder for the body to bathtubs, majority of cases; 50% require warm up. hospital admission for management Cardiovascular Changes: Cardiac Factors Associated with Drowning: output and blood pressure may be weak, Inability to swim, diving injuries, making peripheral pulses undetectable. hypothermia, exhaustion, and alcohol Cardiac arrhythmias may also occur. ingestion o Short explanation: Hypothermia Nonfatal Drowning Process: Onset of can cause a decrease in cardiac hypoxia, hypercapnia, bradycardia, and output and blood pressure, arrhythmias; may result in aspiration and leading to reduced blood flow to terminal gasp extremities and potentially life- Resuscitation: Immediate intervention threatening arrhythmias. essential; hypoxia and acidosis major Other Physiologic complications after resuscitation Abnormalities: Hypoxemia and acidosis Pathophysiologic Changes: Depend may occur. on type of fluid (fresh or salt water) and o Short explanation: Hypothermia volume aspirated; can lead to ARDS, can also lead to low blood pulmonary edema, and respiratory or oxygen levels (hypoxemia) and metabolic acidosis an imbalance of acid-base levels in the body (acidosis). MANAGEMENT Management I. Introduction Removal of wet clothing Management therapeutic goals: maintain Continuous monitoring of vital signs, cerebral perfusion and oxygenation to CVP, urine output, and blood chemistry prevent further damage to vital organs. II. Cardiopulmonary Resuscitation All animal bites must be reported to public health authorities CPR has the greatest influence on Rabies prophylaxis may be necessary if survival; priority is managing hypoxia, the animal cannot be located and rabies acidosis, and hypothermia. vaccination verified Prevention and management of hypoxia involve ensuring an adequate airway and II. Human Bites respiration. Human bites are often associated with sexual assaults or other forms of battery III. Monitoring and Ventilation High risk of infection due to bacteria in human saliva Arterial blood gases are monitored to evaluate oxygen, carbon dioxide, Delayed treatment seeking may occur bicarbonate levels, and pH. ED nurse should inspect bitten tissue for Endotracheal intubation with PEEP signs of infection improves oxygenation, prevents aspiration, and corrects intrapulmonary III. Forensic Evidence shunting. Photographs should be taken for Supplemental oxygen can be given by evidence, including with and without a mask if patient breathes spontaneously; measuring device endotracheal tube is necessary if patient does not breathe spontaneously. Follow guidelines for collecting forensic evidence IV. Hypothermia Management Cleansing with soap and water, antibiotics, and tetanus toxoid Patient is usually hypothermic due to administration as prescribed submersion; degree of hypothermia is SNAKE BITES determined using a rectal probe or Snakebites and Venomous Snakes thermocore measurement device. Prescribed rewarming procedures are Over 2000 of the 6000 snakebites in the started during resuscitation based on US annually are from venomous snakes severity and duration of hypothermia. (Tintinalli et al., 2020) Globally, 4.5-5.4 million people get bitten V. Other Management Strategies by snakes each year, with 81,000- 138,000 deaths from complications Intravascular volume expansion and (WHO, 2019) inotropic agents are used to treat Children between 1-9 years old are most hypotension and impaired tissue likely victims, with most bites occurring perfusion. during daylight hours and early evening ECG monitoring is initiated to monitor for in summer months arrhythmias. Indwelling urinary catheter is inserted to Types of Snakebites measure urine output. Most common poisonous snakebite in Nasogastric intubation is used to the US is from Crotalidae (pit vipers) such decompress the stomach and prevent as water moccasins, copperheads, and aspiration. rattlesnakes VI. Post-Resuscitation Care 75-80% of pit viper bites result in envenomation, while the rest are dry bites (Tintinalli et al., 2020) Close monitoring continues with serial vital signs, arterial blood gas values, Venomous snakebites are medical ECG monitoring, intracranial pressure emergencies assessments, serum electrolyte levels, Regional Variations intake and output, and serial chest x- rays. 19 different species of venomous snakes Patient is at risk for complications such are found in various regions of the US as hypoxic or ischemic cerebral injury, Nurses should be familiar with local ARDS, and life-threatening cardiac snake species arrest. Patient is also at heightened risk for Exotic pet industry sells non-native aspiration due to vomiting. snakes as "pets", which can lead to encounters with venomous snakes outside their native region ANIMAL AND HUMAN BITES Snake Venom Clinical Manifestations I. Animal Bites 1. Physiologic Effects Dog bites account for 80-90% of animal Primarily composed of proteins bites Affects multiple organ systems, Cat bites have a high risk of infection due particularly: to Pasteurella in their saliva o Neurologic  o Cardiovascular Suspect envenomation with snakebites, o Respiratory assess progressive signs and symptoms 2. Classic Signs of Envenomation Administer antivenin if worsening tissue injury and evidence of systemic and Edema coagulopathic symptoms Ecchymosis II. Antivenin Options Hemorrhagic bullae Crotalidae polyvalent immune Fab Necrosis at the site of envenomation antivenom (FabAV or CroFab) is most readily available in the US 3. Symptoms Other antivenin formulas may be Lymph node tenderness available outside the US, but may cause Nausea