Emergency Nursing Concepts PDF

NCM 218 - EMERGENCY NURSING CONCEPT AMIE S. PEREZ-AGUJETAS, RN Clinical Instructor Emergency A sudden, urgent, usually unforeseen occurrence requiring immediate action (Dorland's medical dictionary) ○ Ex. Myocardial infarction ○ Ex. Sudden cardiac arrest or ches...

NCM 218 - EMERGENCY NURSING CONCEPT AMIE S. PEREZ-AGUJETAS, RN Clinical Instructor Emergency A sudden, urgent, usually unforeseen occurrence requiring immediate action (Dorland's medical dictionary) ○ Ex. Myocardial infarction ○ Ex. Sudden cardiac arrest or chest pain which eventually leads to cardiac arrest A medical or surgical condition requiring immediate or timely to prevent permanent disability or death ○ Ex. Occupational hazards The care given to patients with urgent and critical needs ○ Ex. difficulty in breathing; chest pain A condition is still considered an emergency situation until it is stable or no longer threatens the client’s integrity or well being ○ prioritize in stabilizing the patient prior to transferring to ex. ICU, other hospitals https://www.youtube.com/watch?v=QvB4dyx-rVk Types of Emergencies L Danger to Life ○ Emergencies that can cause an immediate danger to the life of people involved H Danger to Health ○ Not immediately threatening to life ○ Might have serious implications for the continued health and well-being of a person P Danger to Property ○ Emergencies that do not threaten any people, but do threaten peoples’ property E Danger to Environment ○ Emergencies that do not immediately endanger life, health, or property, but do affect the natural environment and creatures living within it Emergencies are divided into 2 groups: Medical Emergencies ○ All acute psychological crises that are NOT directly caused by traumatic impact to the body ○ Related to internal medicine; do not require surgical intervention we Minor surgeries ○ Ex. MI, stroke, anaphylaxis reaction, asthma, respiratory disease BBB Internal medicine condition Traumatic Emergencies ○ Physiological crises that are directly caused by an impact to the body and generally require surgical intervention. ○ Example: appendectomy , gallbladder removal Emergency Nursing A nursing specialty in which nurses care for patients in the emergency or critical phase of their illness or injury  Skilled in dealing with people in the phase when a diagnosis has not yet been made and the cause of the problem is not known. Patients may range from birth to geriatric The Four Universal Goals of Emergency Nursing Care provider - direct care on patients Educator - educate the patient, watcher, parents, etc. Manager - coordinators of the health team Advocate - protecting patient’s rights: privacy, care & education - confidentiality ( IMPORTANT) Goals of Emergency Nursing 1. Establish a partnership with the patient/relatives 2. Achieve a level of independence in the patient appropriate to the illness or injury 3. To enable the individual to avoid ill-health or injury through self-care, health education, and environmental safety 4. To ensure the maximum effectiveness of nursing and medically prescribed treatment is observed. Scope and Practice of Emergency Nursing 1. Assessment, analysis, nursing diagnosis, planning, implementation of interventions, outcome identification, and evaluation of human responses of individuals in all age groups 2. Care that is complicated by the limited access to medical history and the episodic nature of the health care (make use of secondary assessment, i.e. diagnostic testing) 3. 3. Triage and prioritization (not first come, first serve; to be able to serve more patients) 4. 4. Emergency operations preparedness (i.e. what to do during earthquakes; part of disaster nursing) Emergency Room Team Emergency Response Team ○ Delegates tasks (i.e. bagging, CPR, giving medication, documentation, etc) Triage Team ○ Located in the front of the ER ○ Assesses the patient to see who needs immediate care ○ Segregates patients (i.e. Emergency, surgical, paediatric, OB) Example: chest pain & pregnant → check if not MI. mother may be experiencing GERD ER Resident Doctors ER Nurses Nursing Assistant/Aide Other Personnel in ER Admitting Staff Post Graduate Interns Medical/Respiratory/Nursing Students Respiratory Therapist Medical Technologist/Radiological Technician EMERGENCY NURSE Specialized education, training, experience, and expertise in assessing and  identifying patients’ health care problems in crisis situations. Focused on giving timely care to their patients FUNCTIONS ○ Establishes priorities ○ Monitor and consciously assess pts who are acutely ill and injured ○ Supports and attends to families ○ Supervises allied health personnel ○ Educates pts and families within a time-limited, high pressured care environment. Youtube links: https://www.youtube.com/watch?v=msUI-fSoJLQ https://www.youtube.com/watch?v=Gr18bvqWSW8&feature=youtu.be GENERAL PRINCIPLES OF EMERGENCY MANAGEMENT Remain calm and think before acting Identify oneself as a nurse to victim and bystander - Tell them that you are a nurse. Do a rapid assessment for priority data (ABC) Carry out lifesaving measures as indicated by the priority assessment - ○ DOB → oxygen ○ Pain → pain meds ○ Wound dressing Do a head-to-toe assessment (secondary assessment) before initiating first aid measures ○ i.e. cases like stab wounds, traumatic pts ○ Change pt to hospital gown to assess any further injuries Obtain data from the patient (secure consent) ○ Mentally fit people can sign consent ○ If pt is unable (i.e. drug intoxication), the watcher can give consent Avoid unnecessary handling or moving of victim (esp. if spinal cord injury); move only if danger is present Do not transport the victim until all first aid measures have been carried out and appropriate transportation is available EMERGENCY DEPARTMENT MAJOR GOALS: To preserve life To prevent deterioration before more definitive treatment can be given To restore the patient to useful living To determine the extent of injury or illness To establish priorities for the initiation of treatment DIFFERENT AREAS IN EMERGENCY DEPARTMENT Resuscitation Area ○ Code Blue ○ Need immediate attention Medical Area (IM cases like GERD, cardio, pneumonia, etc) Pediatric Area (17 years old below) Surgical Area (example: suture, dog bite, industrial incidents) OB-GYNE Area (abnormal uterine bleeding, pregnancy)  Minor OR (pt who needs suture, cdt insertion, excision of sebaceous cysts) OPD (patient who don't want to be admitted, check up only) CARE OF EMERGENCY PATIENT Main Goal: recognizing life-threatening illness or injury Priority: initiating interventions to reverse or prevent a crisis before making a medical diagnosis This process begins with your first contact with a patient. Prompt identification of patients who need immediate treatment and Determining appropriate intervention are essential nurse competencies. POSITION STATEMENTS OF EMERGENCY ASSOCIATION ON DIFFERENT ISSUES ACCESS TO HEALTH CARE A. All individuals must have equitable access to comprehensive health care services. B. All factors impeding access to quality health care must be removed C. The use of Emergency Departments for primary care and for non-urgent needs be alleviated by expanding primary and preventive health care services. D. The lack of appropriately prepared nurses and nurse educators deepens health disparities, inflates costs, and exacerbates health care outcomes. E. Emergency nurses must be actively involved in research that contributes to equitable access to health promotion and critical, acute, and chronic health care; and F. Emergency nurses must maintain ongoing continuing education to acquire and enhance knowledge and skills related to community and patient needs, institutional efficiencies, and other issues concerning equitable access to health care. ADVANCED PRACTICE IN EMERGENCY national NURSING ERNAP wemergengnnrsingassooiatim-v.tw emergengmmsingassoantimofthzDhAippih3_ ENA recognizes the contributions of clinical nurse specialists and nurse practisioners in emergency care settings. Advanced practice registered nurses have a broad depth of knowledge and expertise in their specialty area and manage complex and systems issues. ALL HAZARDS All-hazards planning should begin at home Response to a mass casualty event should be organized and coordinated as to maximize the number of lives saved It is essential to integrate responding entities using a common framework applicable to all-hazards All-hazards planning includes utilizing a coordinated community-wide plan that links local, stage, regional, and national resources. The active participation of emergency nurses in hospitals and community-wide drills in preparing for, responding to , and recovering from all-hazards incidents is essential. All-hazards planning must involve care individuals across all age groups and diverse populations. Volunteer responders should participate and deploy as a requested individual, group, or team.  Situations arise during the disaster when it may become necessary to provide care using altered care standards and/or in an altered or less than ideal environment. Development of basic and advanced continuing education course and training is essential to prepare emergency nurses in the care and treatment of all-hazard patient Content of all-hazards disaster medicine and emergency response should be included core curricula for emergency nurses and other health care professionals Emergency nurses should be involved in research related to disaster preparedness topics. HAZARDOUS MATERIAL EXPOSURE A comprehensive and multidisciplinary approach shall be taken for the prevention of hazardous material exposure; Efforts toward an all hazards approach mitigation, planning, and response of hazardous material exposure shall be undertaken; The development of appropriate hazardous material exposure guidelines shall be based on evidence-based practice. Emergency care personnel shall be prepared and knowledgeable regarding the recognition and management of patients exposed to or contaminated with hazardous material; Emergency departments and their associated hospitals shall be prepared to receive and care contaminated patients; Emergency departments and their associated hospital’s staff shall use the appropriate personal protective equipment (PPE) for the management of hazardous material exposure; Best practice is the regionalization and standardization of equipment, supplies, education, and hands-on training as it pertains to the care of contaminated patients; PATIENT SATISFACTION IN THE EMERGENCY DEPARTMENT The primary customers of the emergency department are patients, families, and significant others; Respect for the diversity of patients, families, and significant others are inherent in emergency nursing practice; The actions and interaction of the emergency nurse consistently demonstrate efforts to meet customers’ needs for respect, dignity, and quality care; The emergency department is a unique health care delivery system and that instruments to measure customer service, quality of care, and patient satisfaction must recognize that uniqueness; Standardized measurement and monitoring of customer service, quality of care, and patient satisfaction should be an on-going process within the emergency department and at the national level; The dissemination of accurate information to the public about emergency department services is critical to the perceptions of patients and their families concerning the care they can expect to receive; Continuing education on customer service may improve both patient and staff satisfaction with emergency department care delivery; and Research is needed to measure patient outcomes related to the quality care in emergency departments. ISSUES IN NURSING CARE  intensive tx di inning sa ICU Selective a no , > ✗ - intensive Physician decides fun tx full - ul , , comfort tours - arrest sa house , no larger sa hosp ISSUES IN NURSING CARE for life sustaining treatment order ETHICO-MORAL physician medical Power of Attorney Advance directives living will 1 DNR Documents that indicate what is to be done for a patient in extreme who is no longer able to give or withhold permission for medical treatment Usually written to avoid prolonging an inevitable, often painful or non-sentiment dying process. Do not resuscitate order A physician order in the hospital chart informing other medical personnel that they should not institute CPR in the event of cardiopulmonary arrest. Duty to Act Duty of a party to take necessary action to prevent harm to another party or the general public Breach of duty to act may make a party liable for damages depending on the circumstances and relationship between the parties CONSENT TO TREATMENT - THROUGH INFORMED CONSENT Means that the client is knowledgeable of ALL treatment and procedures and AGREE to these before implementation Must be presented in language in cc the patient understands the implications of any treatment. By being informed: ○ Clients have the right to refuse any treatment or procedures HOWEVER CONSENT IS VALID ONLY ○ If client is of adult years and sound MIND. But Not all adults can give consent especially if HYPOXIC, INTOXICATED OR ALTERED LEVEL OF CONSCIOUSNESS. EMERGENCY DOCTRINE Emergency treatment can be provided under this doctrine The client would have been able to consent to this IF ABLE because the alternative would have been death or disability This removes the needs for obtaining informed consent before emergency treatment and care are initiated. RIGHT TO PRIVACY AND CONFIDENTIALITY Not allowing unauthorized people into the hospital area. Not disclosing private facts. → this is where DOH get the f- statistics MANDATORY REPORTING Laws require hospitals, nurses, physicians as well to notify appropriate local, state or agencies when incidents occur. Ex. Communicable disease: meningitis, meningococcemia, food poisoning. PHYSICAL EVIDENCE AND CHAIN CUSTODY All evidences must be recorded during examination Should be maintained in its natural condition Secure consent to do picture-taking for evidence Examples: Clothings – paper bag to prevent decomposition  of Gunshot wound - Burnt entry - Bullets – MD usually marks the bottom of the bullet and refers to later during investigation or trial. They are placed in a sealed bag, labeled and given to proper authorities. Gunshot wound – photograph and describe the wound Specimen are obtain for legal purposes ○ Ex: Sexual assault victim – tested for alcohol level by propoer person must be documented on his clinical records. TRANSFER LAWS Nurses should be aware of the hospital transfer policies, guidelines and protocols (Prior notification to the hospital is needed) This is done bc of lack of facilities or medical expertise Stabilization, documentation, and specific guidelines must be observed Receiving institution must accept the transfer Transfer will not endanger the patient Qualified personnel in attendance and proper medical equipment should be available REASONS FOR MEDICAL ERRORS 1. Poor training of healthcare staff 2. Patient overcrwoding and doctor understaffing. 3. Patient medical history is mystery to attending staff/personnel 4. Unsanitary or ill equipped facilities 5. Inefficient or effective record keeping policies 6. Unsafe or negligent medication distribution procedures ISSUES IN NURSING CARE LEGAL ERRORS Common Emergency Room Errors have have legal impact are the following: 1. Prescription drug errors or negligent administration of medication 2. Failure to thoroughly assess the patient 3. Performing procedures without securing consent from the patient or relatives DOCUMENTATION AND PRIVACY Patients should be provided with a statement of the privacy policy of the healthcare agency Access to the medical record, both paper and electronic, are strictly held confidential as to provide privacy to the patient. CULTURAL Sociocultural differences between patient and provider may result in miscommunication, distrust, poor treatment adherence, and worse outcomes. Improperly trained clinicians may resort to stereotyping and even biased or discriminatory treatment of patients based on race, ethnicity, culture, language proficiency, or social status ADDITIONAL ISSUES IN EMERGENCY NURSING CARE Documentation of Consent and Privacy Limiting exposure to Health Risks Violence the Emergency Department Providing Holistic Care DOCUMENTATION OF CONSENT AND PRIVACY Consent to examine and treat the patient is part of the ED record. The patient needs to give consent for invasive procedures (e.g. angiography, lumbar puncture). Unconscious or in a critical condition and unable to make decisions DOCUMENTATION THE NURSE MUST DOCUMENT: The patient’s unconscious and brought to the ED without family or friends Monitoring patient’s condition All instituted treatment and the times at which they were performed Response to the treatment Condition at discharge or transfer About instructions given to the patient and family for follow-up care. LIMITING EXPOSURE TO HEALTH RISKS This risk is further compounded in the ED because of the common use of invasive treatments in patients who may have a wide range of conditions and unable to provide a comprehensive medical history. All emergency health care providers must adhere strictly to standard precautions for minimizing exposure. Early identification and strict adherence is crucial. VIOLENCE IN THE EMERGENCY DEPARTMENT Causes: The effects of substance abuse, injury or other emergencies Emotionally volatile patient and families The environment of the ED, including being subjected to long wait times and crowded conditions SAFETY IS THE FIRST PRIORITY PHYSICAL THREATS ARE MOST OFTEN ACCOMPANIED BY VERBAL ABUSE, which is the most common type of violence A patient or family member may come to the ED armed To avoid angry confrontations, members of gangs and families who are feuding need to be separated in the ED The Joint Commision has strict standards regarding documentation of the reason, monitoring for safety, and ensuring the dignity of the patient who is restrained (Solheim, 2016). Precautions to be taken to avoid injury include the following situations: For prisoners, the hand or ankle restaurant (handcuff) is never released, and a guard is always present in the room. A mask can be placed on the patient to prevent spitting or biting Non restraint techniques should be tried when possible - e.g. talking with the patient, minimizing environmental stimulation Physical restraints are used on any patient who is violent only as needed and, if used G- used, should be humanely and professionally given (ACEP) Distance should be maintained from the patient to avoid grabbing; Staff should not wear items that can be grabbed by the patient, such as dangling  jewelry and stethoscopes. Furthermore, distance should be maintained between the patient and the door so that an escape route for the staff member is preserved. Objects should not be left within patient reach; even an intravenous (IV) line spike can be a tool of violence if the patient is determined. Courses on safety (de-escalation and physical restraint techniques) assist the staff with preparing for various violent situations. In the case of gunfire in the ED, self-protection is a priority. Security officers and police must gain control of the situation first, and then care is provided to the injured. PROVIDING HOLISTIC CARE Patients and families are overwhelmed by anxiety because they have not had time to adapt to the crises They experience real and terrifying fear of death, mutilation, immobilization, and other assaults on their personal identity and body integrity. When confronted with trauma, severe disfigurement, severe illness, or sudden death, the family experiences several stages of crisis. The initial goal for the patient and family is anxiety reaction, a e to effective and appropriate coping prerequisite SAFETY is of prime importance. Close observation and pre planning are essential. Security personnel are stationed nearby in the event that a patient or family member responds to stress with physical violence Assessment of the patient and family’s psychological function includes evaluating emotional expression, degree of anxiety, and cognitive functioning Possible nursing diagnoses include: ○ Anxiety or death anxiety related to uncertain potential outcomes of the illness or trauma ○ Ineffective coping related to acute situational crisis. Possible nursing diagnoses for the family include: ○ Grieving Interrupted family processes ○ Compromised or disabled family coping related to acute situational crisis TWO TYPES OF INTERVENTIONS IN ER Patient-Focused Intervention Act confidently and competently to relieve anxiety and promote a sense of security. Explanations should be given so that the patient can understand Human contact and reassuring words reduce the panic of the person who is severely injured or ill and aid in dispelling fear of the unknown The patient who is unconscious should be treated as if conscious Ensuring patient safety is a major focus in clinical practice settings. Some of the most common sentinel in the ED include delays to care and medication errors Common root causes for these sentinel events revolve around ○ Nurse staffing patterns ○ Patient volume ○ Specialty availability Solutions to patient safety issues in the ED include:  mataas ang shifting ○ Ensuring optimal nurse staffing, - ○ Pharmacy presence ○ Rapid diagnostic turnaround times ➔ To minimize wait time to diagnosis and fostering teamwork and support by leadership I Family Focused-Intervention The family is kept informed about where the patient is, how he is, how he or she is doing, and the care that is being given. Encouraging family members to stay with the patient, when possible, also helps allay their anxieties. HELPING FAMILY MEMBERS COPE WITH SUDDEN DEATH 1. Take the family to a private place. 2. Talk to the family together so that they can grieve together and hear the information given together 3. Reassure the family that everything possible was done; inform them of the treatment rendered. 4. Avoid using euphemisms such as “passed on”. 5. Encourage family members to support each other and to express emotions freely. 6. Avoid giving sedation to family members 7. Encourage the family to view the body if they wish. 8. Spend time with the family, listening to them and identifying any needs that they may have for which the nursing staff can be helpful. 9. Allow family members to talk about the deceased and what he or she meant to them. Encourage the family to talk about events preceding admission to the emergency department. 10. Avoid volunteering unnecessary information. TOPIC 2: APPROACHES TO EMERGENCY CARE ER Concept - always do Vfs every px comes before trig ing TRIAGE A French word tier meaning “to sort,” refers to the process of rapidly determining patient acuity. Entails fast assessment of the patient Process of assessing patients to determine management priorities. A method of prioritizing patient care according to the type of illness or injury and the urgency of the patient’s condition. Used to ensure that each patient receives care appropriate to his needs and in a timely manner. https://youtu.be/mygmoUzjrB4 x.my#f-Eoo " cross " OBJECTIVES OF THE TRIAGE Identify patients who require immediate care. Use space and resources efficiently Facilitate patients flow in the ED Provide assessment and reassessment of patient Alleviate fear and anxiety of patients or visitors Foley catheter Initiate legal responsibility.  triage Rules seriousness of color coding to the 1. great the wounded au "" Black - no pulse , no Cpr of need * med " " and urgency then injuries Red - arrest 4 basic Mes yellow - fractured need to assess ambulatory but 5th green - i. even p> home 1 Watcher in the Exam room 2. 3. 4. keep clean CP and Malte ED a cam sanitize safe in your pocket / purse hands ¥Ñ TRIAGE IN HOSPITAL SETTING - The resident (watch) THREE-TIER TRIAGE Emergent ○ Patients require immediate treatment within minutes or patients may die ○ Involves emergency cases with problems in the ABC’s (airway, breathing, and circulation). ○ Within 15-30 minutes. fever but newborn ○ Ex: unconscious, abnormal breathing, lacerated wound (bleeding), eclampsia / Fracture in brain stem Urgent ○ Evacuation is required within two hours to save life or limb; ○ Delay in care may occur for a limited time without significant mortality; ○ Can wait up to 2 hours for Fever Fracture in spine ribs baekpaih , , Non-Urgent needs monitoring - ○ Patients have non-life threatening conditions and likely need only one resource to provide for their needs. ○ More than 2 hours ( 4- 6hrs7 ○ Ex: dysmenorrhea, sebaceous cysts 1 toothache /Fracture Headache / OPD /checkups FIVE-TIER TRIAGE code blue Based on ENA (Emergency Nursing Association) 2011 px Head / chest Trauma spa /Vesna Level 1: Resuscitation ✓ Blue ○ This level Includes patients who need immediate nursing and medical - Code seizing Red - attention, such as those with cardiopulmonary arrest, major trauma, severe Code respiratory distress and seizures. adult code buy Pedi Level 2: Emergent I can wait but intervene Immediately - " code pink - ○ These patients needs immediate nursing assessment and rapid treatment such as head injuries, chest pain (gastric or cardiac problem), stroke, asthma, and sexual assault injuries (only considered if the patient has active bleeding). Level 3: Urgent ○ These patients need quick attention but can wait as long as 30 minutes for an - assessment and treatment, such as signs of infection (fever), mild respiratory distress or moderate pain. Level 4: Less Urgent ○ Patients in this triage category can wait up to 1 hour for an assessment and - treatment such as earache, chronic back pain, upper respiratory symptoms and mild headache L cough limbo / pro) Level 5: Nonurgent ○ These patients can wait up to 2 hours for an assessment and treatment such - as sore throat, menstrual cramps, and other minor symptoms. \ * :¥×v " micro - major 60 EMERGENCY SEVERITY INDEX (ESI) A 5-level triage system that incorporates concepts of illness severity and resource use (e.g., electrocardiogram (ECG), laboratory tests, radiology studies, IV fluids) to determine who should be treated first. The Emergency Severity Index (ESI) is simple to use, five-level triage instrument that categorizes emergency department patients by evaluating both patient acuity and resources. The triage nurse estimates resource needs based on previous experience with patients presenting with similar injuries or complaints. Resource needs are defined as the number of resources a patient is expected to consume in order for a disposition decision to be reached. : resources 1. First, assess the patient for any threats to life (ESI-1) needed to a. Ask “Is the patient in imminent danger of dying?” diagnose px 2. For ESI-2, “is this a high risk… makes kaantog bar not or 3. Next, evaluate patient who do not meet the criteria for ESI-1 or ESI-2 for the number of anticipated…. lit # entering 4. Assign patients to ESI-3, ESI-4, or ESI-5…. 5 lvesonncg I 2 resources if cheek up /gonna ESI 3 -5 - Normal vs if a⑤ vs either Eh 1 / Esk  5. Vital signs are important. Patients assigned to ESI-3 must have normal vital signs. 6. Patients with abnormal vital signs may be reassigned to ESI-2. Signs of dying - no pulse - now : i÷¥ñ%¥%% -. renewing i ¥8 " no ESI ALGORITHM ¥mH¥ A. lImmediate life-saving intervention required: airway, emergency medications, or other hemodynamic interventions (IV, supplemental O2, monitor, ECG or labs DO NOT count); and/or any of the following clinical conditions: intubated, apneic, pulseless, severe respiratory distress, SPO2 resouirces Specialty consultation Phone call to PCP complex procedure 2 :  Simple procedure = 1 (lac repair, Simple wound care (dressings, foley cath) recheck); wound is not active Complex procedure = 2 (conscious Crutches, splints, slings sedation) D. Danger Zone Vital Signs Consider triage to ESI 2 if any vital sign criterion is exceeded. Pediatric Fever Considerations 1 to 28 days of age: assign at least ESI 2 if temp >38.0 C (100.4F) 1-3 months of age: consider assigning ESI 2 if temp. >38.0 C (100.4F) 3 months to 3 years of age: consider assigning ESI3 if: temp >39.0 C (102.2F), or incomplete immunizations, or no obvious source of fever - - EMERGENCY HOSPITAL TRIAGE Category I: Obvious Emergency ○ Treatable life threatening illness or injury ○ Ex: cardiac arrest, chest pain, severe bleeding, shock Category II: Strong Potential for Emergency ○ Serious but not life threatening needs full evaluation/treatment by the physician ○ Acute DOB ○ Burns without airway problems ○ Multiple bone or joint injuries ○ Back injuries with or without spinal damage Category III: Potential Emergency ○ Pending emergency condition ○ Abdominal pain  ○ High fever Category IV: No Reason for Emergency ○ Outpatient Department (OPD) Cases ○ Mild URTI ○ Sore Throat ○ Low Grade Fever TRIAGE IN MASS CASUALTIES (COLOR CODED) Mass casualty Triage categories Incident EXPECTANT- black triage tag node 1 dead on incident Victim unlikely to survive given severity of injuries, level of available care, or both Palliative care and pain relief should be provided IMMEDIATE - thick border red triage tag node Victim can be helped by immediate intervention and transport Requires medical attention within minutes for survival (up to 60) Includes compromises to patient’s airway, breathing, circulation DELAYED - dotted border yellow triage tag node Victim’s transport can be delayed Includes serious and potentially life-threatening injuries, but status not expected to deteriorate significantly over several hours MINOR - Dashed border green triage tag node start Victim with relatively minor injuries Triage Status unlikely to deteriorate over days May be able to assist in own care; “walking wounded” And Rapid Triage (sorting casualties) Treatment RED: Priority I (Immediate) Urgent resuscitative interventions are required for survival. It is likely that individuals will die within 2 hour earlier without treatment Ie: airway obstruction shock, severe trauma YELLOW: Priority 2 (Urgent) Require early treatment, for example surgery, and patients should be evacuated to a surgical facility within 6 hours of injury. Ie. visceral injuries, limb fractures, closed head injury, eye injury, burns. GREEN: Priority 3 (Delay or Hold) Treatment can be deferred if there are other casualties requiring evacuation. These patients are ambulatory and follow commands. I.e: closed fractures, soft tissue injury, closed chest injury, maxillofacial injury BLACK: Priority 4 (expectant or deceased) Minimal chance of survival, and if there is competition for limited medical resources, such cases will have lower priority for evacuation and treatment  gasping - spontaneous Breathing Bagga PRIMARY SURVEY Bullhorn! Rrzo Pz "µt÷! :* aims to identify life-threatening conditions so that appropriate interventions can be CAB - BLS started - Acts ABCDEA- AIRWAY AND ALERTNESS B- BREATHING / C- CIRCULATION catastrophic Hemorrhage D- DISABILITY E- EXPOSURE site F- FACILITATE ADJUNCT AND FAMILY [Adults ) intubation Blade i 2 a 3 G- GET RESUSCITATION ADJUNCTS - maintain patent airway A – Airway and Alertness Saliva, bloody secretions, vomitus, laryngeal trauma, dentures, facial trauma, fractures, and the tongue can obstruct the airway Patients at risk for airway compromise include those who drown or have seizures, anaphylaxis, foreign body obstruction, or cardiopulmonary arrest If an airway is not maintained, obstruction of airflow, hypoxia, and death will result Signs and symptoms in a patient with a compromised airway include: ○ dyspnea ○ inability to speak AMWAY - ○ Gasping (agonal) breaths - sign of di ok ang airway / need trauma Tkhgt ○ Foreign body in airway ○ Trauma to the face and neck The patient’s alertness level is a crucial factor for choosing the right airway interventions. Determine level of consciousness (LOC) by assessing the patient’s response to verbal and/or painful stimuli. A simple mnemonic to remember is AVPU: - ALERTNESS ○ A- Alert ○ V- responsive to voice airway - positioning admission Procedure 1. Place / transfer px in stretcher / wheel technique :* carry px 4 lift sheet /sled * log rolling * sliding tehniqne / slide board * pivot technique 2. record pertinent data of px y name / age * cc admission / check up? * name of Dr * * V5 / weight 3- vs lang always ang i - write for forms 3- assist pxin lying pos. on bed offer blanket , route side rails 4. perform assessment Cgensuwg) ad his taking CPQNST } SAMPLE ) 5. assist in puce * IM * IV start /assist I f- c insert * Not Feed /med * changing going/diaper * gnig PO meds town 0C 6- assist in transporting 7- endorse to NOD * Bmg logbook - Room { bed # - TPR CIntervention - px name / age Mgmt) Crespo to tx) - Cc - Dy in ER - attending physician lseen { assessed) v1 still for - Diet iw-crat.lv) dlt) 8- return to ER 4 perform after care Be ready to rat pox q. again for admission  ○ P- responsive to pain ○ U- unresponsive Airway maintenance should progress rapidly from the least to the most invasive method. Treatment includes: 1. Opening the airway using the jaw-thrust maneuver (avoiding hyperextension - of the neck) 2. Suctioning and/or removal of foreign body 3. Inserting a nasopharyngeal or oropharyngeal airway (in unconscious patients only 4. Endotracheal intubation Rapid-Sequence Intubation ○ The preferred procedure for securing an unprotected airway in the ED. ○ It involves the use of sedatives and paralytic drugs. ○ These drugs aid in intubation and reduce the risk for aspiration and airway trauma. 7 P’s of RSI Preparation: for 10 minutes, to see and assess the patient if i intubate or not, part of preparation is “Imaging” if BLS 11,2 pump Pre-oxygenation: give oxygen to the patient prior to intubation, patient were E(PuwppÉppwp given high flow oxygen if oxygen saturation of the patient is low (hyperoxygenation: to maintain 95 to prevent hypoxia); for 3-5 minutes Pre-Treatment: LOAD; will last for 3 minutes L- Lidocaine O- Opioids A- Atropine if anesthesiologist : PROPOFOL D- Defasciculation Paralysis with Induction: we give succinylcholine 1.5mg/kg IVP (IV push); sedative to calm patient and makes it easier to intubate Protection: this is when we do the Sellick’s Maneuver (hyperextend pt’s neck to make laryngeal area more visible, then apply gentle pressure to the anterior neck) Placement of intubation set: ready to intubate pt; do within 45 seconds to 1 minute Post-Intubation Management (Plaster - secure the tube) (after this, we can place the patient into mechanical vetilator) If the patient has a suspected spinal cord injury and is not already immobilized, the cervical must be stabilized at the same time as the assessment of the airway. This can be done with manual stabilization or the use of rigid cervical collar (C collar) Keep the bed flat and continue to monitor airway patency and breathing effectiveness. Alertness and Airway WIth Cervical Spine Stabilization and/or Immobilization Assessment Interventions Assess for catastrophic external Control bleeding with direct pressure bleeding and pressure dressings.  Assess alertness (e.g., AVPU) Open airway using jaw-thrust maneuver Assess for respiratory distress Remove or suction any foreign bodies Determine airway patency Insert oropharyngeal or nasopharyngeal airway, tracheostomy Check for loose teeth or foreign Initiate rapid sequence intubation bodies Assess for bleeding, vomitus, or Immobilize cervical spine using rigid edema cervical collar and cervical immobilization device. 02 Provide supplemental B – Breathing - - Gove BVM - adequacy of vent { oxy should be monitored Adequate airflow through the upper airway does not ensure adequate ventilation Many problems cause breathing changes. Common one include: ○ Fractured ribs ○ Pneumothorax ○ Penetrating injury ○ Allergic reactions ○ Pulmonary emboli ○ Asthma attacks The patient may have: ○ Dyspnea ○ Paradoxical or asymmetric chest wall movement ○ Decreased or absent breath sounds on the affected area ○ Visible wounds to the chest wall ○ Tachycardia ○ Hypotension Breathing Assessment Interventions Assess ventilation Give supplemental O2 via appropriate delivery system (eg. non rebreather mask). Scan chest for signs of breathing Ventilate with a bag-valve-mask with  100% O2 if respirations are inadequate or absent. (10L/min) 95 below pwde pa mag nasal cannula Look for paradoxical movement of Prepare to intubate if severe the chest wall during inspiration and respiratory distress (e.g. agonal expiration breaths) or arrest Note use of necessary muscles or Have suction if available. abdominal muscles Observe and count respiratory rate If absent breath sounds, prepare for needle thoracostomy and chest tube insertion. Note color of nail beds, mucous membranes Auscultate lungs Assess for jugular venous distention and trachea position " mediate " " PM Nessun to treated sa F. C – Circulation /Catastrophic hemorrhage An effective circulatory system includes the heart intact blood vessels, and adequate blood volume Uncontrolled internal or external bleeding places a person at risk for hemorrhagic shock. Circulation Interventions Interventions Check carotid or femoral pulse If absent pulse, start cardiopulmonary resuscitation and advanced life support measures Palpate pulse for quality and rate If shock symptoms or hypotensive, start 2 large- bore (14-16 gauge) IVs and start infusion of normal saline or lactated Ringer’s solution double access , wide open Assess skin color, temperature, venous access if IV access cannot moisture be rapidly obtained Consider intraosseous or central Check capillary refill Give blood products if ordered. r check Cort - obtain Nanae bhudry altan leads eeg - cantor assess } -  D – Disability Conduct a brief neurologic examination as part of the primary survey. The patient’s LOC is a measure of the degree of disability. Use the Glasgow Coma Scale (GCS) to determine the LOC. This allows for consistent communication among the inter professional care team Remember! The GCS is not accurate for intubated or aphasic patients. Last, assess the pupils for size, shape, equality, and reactivity. E – Exposure and Environmental Control Remove clothing from all trauma patients to perform a thorough physical : scissors assessment. This often requires cutting off the patient’s clothing silks Be careful not to cut through any area that is forensic evidence (e.g., bullet hole). chroma Do not remove any impaled objects (e.g. knife). Removing these could result in serious bleeding and further injury Once the patient is exposed, use warming blankets, overhead warmers, and warmed IV fluids to limit heat loss, prevent hypothermia, and maintain privacy F – Facilitate Adjunct and Family Research supports the benefits for patients, caregivers, and staff of allowing family presence during resuscitation and invasive procedures. Patients report that caregivers provide comfort, serve as advocates for them, and help remind the care team of their “personhood” Caregivers who wish to be present during invasive procedures and resuscitation view themselves as active participants in the care process. Facilitate Adjuncts and Family CONFIDENTIAL Assessment Interventions Assess vital signs and pulse Obtain bilateral blood pressure if oximetry patients have sustained or are suspected of having sustained chest trauma, or if the BP is abnormal. Determine caregiver’s desire to be Assign health team members to present during invasive procedures support caregiver(s). and/or cardiopulmonary resuscitation Provide emotional support to patient and caregiver. G – Get Resuscitation Adjuncts L: Laboratory tests M: Monitor ECG for heart rate and rhythm N: Nasogastric (NG) tube - for oral medication O: Oxygenation and ventilation assessment P: Pain assessment and management - if there is a present of pain to the patient.  NOI POI Tol Dol - surgical ¥☒ , , ' , - trauma Iae i ± SECONDARY SURVEY An assessment of the patient triaged to the emergent or resuscitation category that commences after the primary survey is completed and life-threatening insults addressed. Interview It includes obtaining vital signs, completing a head-to-toe examination, and obtaining the patient’s pertinent medical-surgical history, including the history of the current event. A brief, systematic process that aims to identify all injuries. It is valuable for discovering unknown problems in patients with a poor or confusing history. HISTORY AND HEAD-TO-TOE ASSESSMENT Obtain a history and mechanism of the injury or illness. These details provide clues to the cause and guide specific assessment and interventions The patient may not be able to give a history. However, caregivers, friends, bystanders, and pre-hospital personnel can often give necessary information. SAMPLE is a memory aid that prompts you to ask about: complete Hy ➔ S: Symptoms/ Subjective cues ➔ A: Allergies and tetanus status - Pre - hospital Information Aunt ➔ M: Medication history - px data ➔ P: Past health/ medical history medical Ax ➔ L: Last meal/ oral/ menses - past ➔ E: Event or environmental factors leading to injury Healthcare - cx S: Symptoms/ Subjective Cues What does the patient say? How did the accident occur? Does he remember? What symptoms does he report? A: Allergies Does the patient have allergies? What are they allergic to? Is he wearing a medical identification bracelet? M: Medication History Does the patient take medications on a regular basis? What are the medications? What medications has he taken in the past 24 hours? P: Past Health/ Medical History Has the patient been treated for medical conditions and if so, which ones? Has the patient had surgery? What type of surgery? When? Which doctor? L: Last meal/ oral/ menses/ tetanus shot When was the last time the patient had anything to eat or drink? When did he have his most recent tetanus shot? If the patient is a female of childbearing age, when was her last menses?  Could she be pregnant? E: Events or environmental factors leading to injury How does the accident occur? NOI (Nature of Incident), TOI (Time of Incident), DOI (Date of Incident), POI (Place of incident) - commonly asked questions for patient suffering from falls or vehicular accidents ASSESSMENT Types of Assessment Type Time Performed Purpose Example Initial Performed Assessment To establish a Nursing admission within specified complete assessment time after database for admission to a problem health care identification, agency. reference, and future comparison Problem-foc Ongoing us ed To determine the assessment Hourly assessment process status of a specific of client’s fluid intake integrated with problem identified and urinary output in nursing care Emergency in an earlier assessment an ICU. assessment. Assessment of client’s ability to perform self-care while assisting a client to bathe. During any To identify Rapid assessment physiological or life-threatening of an individual’s  psychological problems airway, breathing crisis of the status, and client To identify new or circulation during a overlooked cardiac arrest. problems Assessment of suicidal tendencies or ptotaential for violence. Time-Lapse Several months d To compare the Reassessm Reassessment of a ent after initial client’s current client’s functional assessment status to baseline health patterns in a data previously home care or obtained outpatient setting or, in a hospital, at shift change. HEAD, NECK, AND FACE Head, neck, and face Note general appearance, including skin color. Assess face and scalp for laceration, bone of soft tissue deformity, tenderness, bleeding , foreign bodies. Inspect eyes, ears,nose, and mouth for bleeding, foreign bodies, drainage, pain, deformity, bruising , lacerations. Palpate head for depressions of cranial or facial bones , contusions, hematomas, areas of softness, bony crepitus. Assess neck for stiffness, pain in cervical vertebrae, tracheal deviation,distended neck veins,  bleeding edema, difficulty swallowing bruising subcutaneous emphysema, bony crepitus. Check eyes for extraocular movements. A disconjugate gaze is a sign of neurologic damage. Battle’s sign, or bruising directly behind the ears, may indicate a fracture of the base or posterior part of the skull. “Raccoon eyes” or periorbital bruising, usually occurs with a fracture of the base of the frontal part of the skull. Check the ears for blood and cerebrospinal fluid. Do not block clear drainage from the ear or nose. CHEST Chest Observe rate, depth, and effort of breathing, include chest wall movement and use of accessory muscles Palpate for bony crepitus and subcutaneous emphysema Auscultate breath sounds Obtain 12-lead ECG and chest x-ray Inspect for external signs of injury: petechiae, bleeding cyanosis, bruises, abrasions, lacerans, old scars Inspection and palpation of the chest will clue the nurse for heart and lung injuries These may be life threatening and may need immediate intervention ABDOMEN AND FLANKS Abdomen and Flanks Look for symmetry of abdominal wall and bony structures Inspect for external signs of injury: bruises, abrasions, lacerations, punctures, old scars. Auscultate for bowel sounds Palpate for masses, guarding, femoral pulses. Note type and location of pain, rigidity, or distention of abdomen Frequent evaluation for subtle changes in the abdomen is essential Motor vehicle crashes and assaults can cause blunt trauma. Penetrating trauma tends to injure specific organs. Stabilize, but do not remove any implanted objects. They must be removed in a controlled environment, such as the operating room Focused abdominal sonography for trauma (FAST)- hemorrhage and Cardiac fnx- CT scan is better. PELVIS AND PERINEUM Pelvis and Perineum Gently palpate the pelvis. Assess genitalia for blood at the meatus, priapism, bruising, rectal bleeding, and sphincter tone. Determine ability to void. Inspect and gently palpate the pelvis. Do not rock the pelvis. Pain may indicate a pelvic fracture and the need for imaging. Assess for bladder distention, hematuria, dysuria, or inability to void. The HCP may perform a rectal examination to check for blood, prostate gland problems, and loss of sphincter tone (e.g. spinal cord injury. EXTREMITIES Extremities Inspect for signs of external injury: deformity, bruising, abrasions, lacerations, swelling. Observe skin color and palpate skin for pain, tenderness, temperature, and crepitus. Evaluate movement, strength, and sensation in arms and legs. Assess quality and symmetry of peripheral pulses. Assess the upper and lower If not done prehospital, splint injured extremities above and below the injury to decrease further soft tissue injury and pain. The HCP should realign deformed, pulseless extremities before splinting Check pulses before and after movement or splinting of an extremity A pulseless extremity is a time-critical emergency Immobilize and elevate injured extremities and apply ice packs. Antibiotics are given for open fractures to prevent infection. Assess extremities for compartment syndrome INSPECT POSTERIOR SURFACES Inspect posterior surfaces Logroll and inspect and palpate back for deformity, bleeding, lacerations, bruises. Maintain cervical spine immobilization, if appropriate. An often overlooked part of the assessment is the back of the patient. Logroll the trauma patient while protecting the cervical spine. Up to 4 or more people with 1 person supporting the head may be needed to complete this assessment. COMPLETE HISTORY Pre-Hospital Information (MIVT) ○ Mechanism of Injury ○ Injury sustained/suspected ○ Vital signs ○ Treatment Patient’s Data Past Medical History/Client’s Healthcare History - PQRST Component Sample Questions P (Provokes) What provokes the symptoms? Q (Quality) What makes it better? What makes it worse? What does it feel like? R (Radiation) Where is it? Where does it go? Is it in one or more spots? S (Severity) If we gave it a number from 0 to 10, with 0 being none and 10 being the worst you can imagine, what is your rating? T(Time) How long have you had the symptoms? When did it start? When did it end? How long does it last? Does it come and go? ACUTE CARE AND EVALUATION Once the secondary survey is complete, record all findings Give tetanus prophylaxis based on vaccination history and the condition of any wounds Ongoing monitoring and evaluation are critical The evaluation of airway patency and the effectiveness of breathing is always the highest priority. Monitor respiratory rate and rhythm, O2 saturation, and ABGs (if ordered) to evaluate the patient’s respiratory status Closely monitor LOC Insert an indwelling catheter when indicated Depending on the patient’s injuries or illness, the patient may be: ○ Transported for diagnostic tests (e.g., CT Scan, angiography) or to the operating room for immediate surgery; ○ Admitted ○ Transferred to another facility You may go with critically ill patients on transport CARDIAC ARREST AND TARGETED TEMPERATURE MANAGEMENT Many patients arrive at the ED in cardiac arrest Patients with non traumatic, out-of-hospital cardiac arrest benefit from a combination of good chest compressions and rapid defibrillation, targeted temperature management (TTM), and supportive care. TTM for at least 24 hours after the return of spontaneous circulation (ROSC) decreases mortality rates and improves neurologic outcomes in many patients DEATH IN THE EMERGENCY DEPARTMENT Death occurs when all vital organs and bloody systems cease to function. It is the irreversible cessation of cardiovascular, respiratory, and brain function. End-of life care EOL care focuses on physical and psychosocial needs for the patient and family. The goals of EOL care are to: ○ Provide comfort and supportive care during the dying process ○ Improve the quality of the patient’s remaining life ○ Help ensure a dignified death ○ Provide emotional support to the family An autopsy may be done at the family’s request, or if death occurred within 24 hours of ED admission, from suspected trauma or violence, or in an unusual way. Potentially be candidates for non-heart-beating donation. (corneas, heart valves, skin, bone, and kidneys). Organ procurement organizations aid in screening potential donors, counseling donor families, obtaining informed consent, and harvesting organs from patients who are on life support or who die in the ED. The act of donation may be the first positive step in the grieving process. GERONTOLOGIC CONSIDERATIONS: EMERGENCY CARE Regardless of a patient’s age, aggressive interventions are provided unless, extremely low chance of survival, or an advance directive indicating a different course of action. Falls are the leading cause of injury. The most common causes of falls in older adults are generalized weakness, environmental hazards, syncope, and orthostatic hypotension. When assessing a patient who has fallen, determine whether the physical findings may have caused the fall or are due to the fall itself. Partial - Hypoxia , Hypevcavbia occluded arrest TOPIC 3: MEDICAL EMERGENCIES [ completely respiratory - brain and cardiac injury (3-5 mins 2ndany AIRWAY OBSTRUCTION - Acute upper airway obstructions is a life-threatening medical to hypoxia) emergency Pathophysiology Partially completely occluded. Partial obstruction of the airway can lead to progressive hypoxia, hypercarbia, and - respiratory and cardiac arrest. = Completely obstructed absent air movement causes permanent brain injury or death will occur within 3 to 5 minutes secondary to hypoxia. The airway prevents entry of air into the lungs causing decreased oxygen saturation. Decrease oxygen in the brain, resulting in unconsciousness, with death following rapidly. Causes Common causes (vomitus, food, edema, tongue, teeth, saliva) Aspiration of foreign bodies Anaphylaxis- most common- causing laryngospasm Inhalation or chemical burns to head, face, or neck areas Viral or bacterial infection in the laryngeal area Tenacious secretions in the airway Cerebral Disorders (stroke: dysphagia causes saliva to build up in oral cavity) Trauma of the face, trachea or larynx Croup (excessive coughing) Peritonsillar or pharyngeal abscesses Epiglottitis Acute infectious processes of the posterior pharynx Causes in Older Adults Sedative and hypnotic medications Diseases affecting motor coordination (e.g., Parkinson disease) Asphyxiation (e.g., dementia, intellectual disability) Atrophy of the posterior pharynx- resulting in aspiration or difficulty swallowing. Aspiration of a bolus of meat is the most common cause of airway obstruction Clinical Manifestations Partial Airway Obstruction Restlessness Agitation and anxiety Diaphoresis Tachycardia Coughing Stridor Respiratory distress Elevated blood pressure Complete Airway Obstruction Universal choking sign- clutches throat with hands Inability to talk Sudden onset of choking or gagging Stridor Cyanosis Wheezing, whistling or any unusual breath sound that indicates breathing difficulty Diminished breath sounds (bilateral/unilateral) Sense of impending doom Progression to unconsciousness ASSESSMENT AND DIAGNOSTIC FINDINGS Conscious Conscious: Ask whether he or she is choking and requires help Unconscious: inspection of the oropharynx may reveal the offending object  Chest and neck X-rays, laryngoscopy, or bronchoscopy, CT scan Auscultation Oxygen supplementation should be considered immediately MANAGING PARTIAL OBSTRUCTION Patient can breathe and cough spontaneously -wheezing between coughs. Encouraged to coughing forcefully. Persistent spontaneous coughing - leading to good air exchange exists MANAGING COMPLETE AIRWAY OBSTRUCTION Head-Tilt Chin-Lift Maneuver & Jaw Thrust Maneuver Rapid assessment of airway patency, breathing, and circulation are foremost. Promptly assess the cause of obstruction Promptly remove objects visible in the mouth ET intubation and removal of foreign object during insertion of the laryngoscope enables visualization of the obstruction Emergency cricothyrotomy is indicated.. NASOPHARYNGEAL AIRWAY Provides the same airway access but is inserted through the nares. CI: potential facial trauma or basal skull fracture. If breathing is ineffective or absent, bag-valve- mask ventilation is necessary BAG- VALVE- MASK (BVM) VENTILATION Is the standard method for rapidly providing rescue ventilation to patients with apnea or severe ventilatory failure. BVM ventilation, a self-inflating bag (resuscitator bag) is attached to a non rebreathing valve and then to a face mask that conforms to the soft tissues of the face. The opposite end of the bag is attached to an oxygen source (100% oxygen) and usually a reservoir bag. The mask is manually held tightly against the face, and squeezing the bag ventilate the patient through the nose and mouth Successful BVM ventilation requires technical competence and depends on 4 things: A patent airway An adequate mask seal Proper ventilation technique PEEP valve as needed to improve oxygenation ENDOTRACHEAL INTUBATION Purpose: To establish and maintain the airway in patients with respiratory insufficiency Bypass an upper airway obstruction, Prevent aspiration 2-3 cc dI⇐! Permit connection of the patient to a resuscitation bag or mechanical ventilator Facilitate the removal of tracheobronchial secretions Indication: Patient who cannot be adequately ventilated with an oropharyngeal or nasopharyngeal airway Surgical procedures - medications used to facilitate rapid sequence intubation include a sedative, an analgesic, and a neuromuscular blockade agent. Performed only by: Those who have had extensive training Physicians Nurse anesthetists Respiratory therapists Flight nurses Nurse practitioners The emergency nurse commonly assists with intubation CRICOTHYROIDOTOMY (CRICOTHYROID MEMBRANE PUNCTURE) Cricothyroidotomy is the opening of the cricothyroid membrane to establish an airway. This procedure is used in emergency situations in which endotracheal intubation is either not possible or contraindicated, INDICATION:  Extensive maxillofacial trauma Cervical Spine Injuries Laryngospasm, Laryngeal edema (after an allergic reaction or extubation) Hemorrhage into neck tissue Obstruction of the Larynx ➔ A cricothyroidotomy is replaced with a formal tracheostomy when the patient is able to tolerate this procedure. TOPIC 4: ACUTE HEMORRHAGE/BLEEDING Abnormal internal or external blood may be caused by suture failure, clotting abnormalities, dislodged clot, infection, or erosion of a blood vessel by a foreign object (tubing, drains) or infection process A rapid loss of circulation intravascular volume ○ Also called BLEEDING or BLOOD LOSS ○ Internal bleeding- refer to blood loss inside the body Occurs when blood leaks out through a damaged blood vessel or organ ○ External Bleeding- or blood loss of the body Happens when blood exits through a break in the skin. Hemorrhage that results in the reduction of circulating blood volume is the main cause of shock. Minor bleeding, which is usually venous, generally stops spontaneously - unless the patient has a bleeding disorder or has been taking anticoagulant agents. Retroperitoneum, pelvis, chest, thighs, etc. Hemorrhage/Bleeding The goals of emergency management are to: 1. Control the bleeding 2. Maintain adequate circulating blood volume for tissue oxygenation 3. Prevent shock MANIFESTATIONS Cool, moist skin (resulting from poor peripheral perfusion Decreasing blood pressure Increasing heart rate Delayed capillary refill Decreasing urine volume ➔ HYPO TACHY TACHY - shock MANAGEMENT Hemorrhaging- externally or internally- a loss of circulating blood results in a fluid volume deficits and decreased cardiac output FLUID REPLACEMENT 1. IV catheters are inserted- 2 large bore cannula uninjured extremity 2. Blood  samples are obtained for analysis, typing, and cross-matching 3. Replacement fluids-isotonic electrolyte solutions (e.g., lactated Ringer’s, normal saline), colloids, and blood component therapy 4. Massive blood loss-PRBC, PLT, Clotting factor CONTROL OF EXTERNAL HEMORRHAGE Rapid physical assessment- identify the area of hemorrhage-cut clothing Calm the patient - anxiousness increases BP Apply direct, firm pressure- bleeding area or the involved artery-proximal to the wound. Elevate affected part- to stop venous and capillary bleeding Immobilized if the affected part is extremity Apply tourniquet - external hemorrhage cannot be controlled-until surgery can be performed - proximal to the wound Patient is tagged with, location & time at forehead Traumatic amputation with uncontrollable hemorrhage - tourniquet remains in place until OR Time of application and removal should be documented. CONTROL OF INTERNAL BLEEDING Manifestation: Internal hemorrhage exhibits tachycardia, falling blood pressure, thirst, apprehension, cool and moist skin, or delayed capillary refill. Treatment: Packed red blood cells, plasma, and platelets are given at a rapid rate. Definitive Treatment: Surgery, pharmacologic therapy, arterial blood gas Establish baseline hemodynamic parameters The patient is maintained in the supine position and monitored closely until hemodynamic or circulatory parameters improve, or until he or she is transported to the operating room or intensive care unit. WOUND A break in the continuity of a tissue of the body either internal or external. OPEN WOUND The skin is interrupted, exposing the tissues underneath. Results from interruption from outside (e.g. laceration or from inside like the fractured bone end tears outward through the skin. CLOSED WOUND Internal injury; no open pathway to the injured site. Results from an impact of a blunt object (e.g. motor vehicle accidents, falls) TYPES OF WOUNDS CLOSED WOUND Contusion - bleeding beneath the skin into the soft tissue Hematoma - also called blood tumor; caused by damage to a blood vessel that in turn causes blood to collect under the skin Bruises Crash Injuries OPEN WOUND Abrasion- simple scratches and scrapes (outer skin is damage) Puncture- occurs when the skin is penetrated by a pointed object. Can be penetrating or perforating. Laceration- a wound that occurs when skin, tissue, and/or muscle is torn or cut open. Avulsion- involves a tearing off or loss of a flap of skin. - flaps of skin and tissues are torn loose or pulled off completely. Amputation - traumatic cutting or tearing off of a finger, toe, arm or leg ➔ NOTE: Wrap or place the amputated part in a plastic bag. Place it in a cooler container so that it is on top of a cold pack! ➔ DO NOT IMMERSE THE AMPUTATED PART IN ICE, COOL WATER OR SALINE FOUR MAJOR PROCEDURES IN CONTROLLING BLEEDING: ➔ Direct Pressure ➔ Elevation ➔ Pressure Points ➔ Tourniquet HYPOVOLEMIC SHOCK The sequence of events in hypovolemic shock begins with the following: Decrease in the intravascular volume This results in decreased venous return of blood to the heart and subsequent decreased ventricular filling Decreased ventricular filling results in decreased stroke volume (amount of blood ejected from the heart) and decreased cardiac output When cardiac output output drops, bp drops and tissues cannot be adequately perfused  Resulting to shock EMERGENCY CARE FOR OPEN WOUNDS Expose the wound Clean the wound surface Control bleeding Prevent further contamination Bandage the dressing in place after bleeding has been controlled Keep patient lying still Reassure patient Care for shock DRESSING/ COMPRESS Any material use to cover a wound that will help in ○ Controlling bleeding ○ Preventing infection and contamination ○ Absorbing blood and fluid drainage ○ Protecting the wound from injury TYPES OF DRESSING BULKY DRESSING Thick single dressing or a build up of thin dressing for profuse bleeding, stabilization of impaled objects and covering of large open wounds. E.g. sanitary napkins, layers of gauze. OCCLUSIVE DRESSING A dressing used to create an airtight seal or close an open wound of an air tight seal or close an open wound of a body cavity. Usually made of folded plastic wrap or bag. LATEST TREND IN WOUND DRESSING Dry wound dressing - OS pack Moist wound dressing- e.g bactederm BANDAGES ➔ Any material that is used to hold a dressing in place. Purposes Hold a dressing in place Apply direct pressure over a dressing Prevent or reduce swelling Provide stability for an extremity Extend (e.g. broken bones) Types of Bandages Triangular Bandage Roller / Elastic Bandage Muslin Binder - Abdominal Binder Adhesive Tapes Adhesive Strips RULES FOR DRESSING AND BANDAGES RULES FOR DRESSING Control bleeding Use sterile or clean materials Cover the entire wound Do not remove the dressing RULES FOR BANDAGES Do not bandage too tightly or too loosely Do not leave loose ends Do not cover fingers toes Bandage from the bottom of a limb to the top (distal to proximal) in elastic bandage Do not square knot tying and should be clean, fast, and smooth. Hypovolemic Shock External: Fluid losses Internal: Fluid shifts Trauma Hemorrhage Surgery Burns Vomiting Ascites Diarrhea Peritonitis Diuresis Dehydration Diabetes Insipidus Necrotizing Pancreatitis Major goals in the treatment of hypovolemic shock: Restore intravascular volume to reverse the sequence of events leading to inadequate tissue perfusion. To redistribute fluid volume. To correct the underlying cause of the fluid loss as quickly as possible. ANAPHYLAXIS A clinical response to an immediate (type 1 hypersensitivity) immunologic reaction between a specific antigen and an antibody. The reaction results from a rapid release of IgE-mediated chemicals, which can induce a severe, life-threatening reaction (Abbas et al., 2014). The reaction typically occurs within minutes but can occur up to 1 hour after exposure to antigen. It produces physical distress within seconds or minutes after exposure. ○ A delayed or persistent reaction may occur up to 24 hours. ○ The severity of the action is inversely related to the intervals between exposure to the allergen and the onset of the symptoms. WHAT CAUSES IT?  ANAPHYLAXIS usually results from ingestion of, or other systemic exposure to, sensitizing drugs or other substances such as: Serum (horse serum) Local anesthetics esther - Vaccines Salicylates Allergen extracts Polysaccharides Enzyme (L-asparginase) Diagnostic chemicals Hormones Food protein Penicillin or other Food additives containing constrictedlungs antibiotics sulfite Sulfonamide Insect Venom ÷÷÷:* > > Bradykinin , > mediators TX : EPI before Antihistamine RESPONSE TO ANTIGEN Upon exposure, IgM and IgG recognize the antigen and bind to it. Patient has no signs and symptoms at this stage. RELEASED CHEMICAL MEDIATORS Activated IgE on basophils promotes the release of mediators including HISTAMINE, SEROTONIN and LEUKOTRIENE Patient begins to have sudden nasal congestion; itchy, watery eyes; flushing; sweating; weakness and anxiety. INTENSIFIED RESPONSE Activated IgE stimulates mast cells in connective tissue along the venule walls to release more histamine and eosinophil chemotactic factor of anaphylaxis (ECF-A). Patient may experience red, itchy skin; wheals and swelling appear. DISTRESS In the lungs, fluids leak into the alveoli thus reducing pulmonary compliance. Patient may experience tachypnea, crowing, use of accessory muscles and cyanosis signal respiratory distress. Neurologic function involves changes in the level of consciousness, severe anxiety and possibly, seizure. DETERIORATION Basophils and mast cells begin to release prostaglandins and bradykinin along with histamine and serotonin These substances increase vascular permeability causing fluid to leak from the vessels Patient become confuse with cool pale skin, generalized edema, tachycardia and hypotensive thus signals rapid vascular collapse FAILED COMPENSATORY MECHANISM Further deterioration occurs