Medical Surgical 3 Finals - MS3-Unit-6 PDF

Medical surgical 3 UNIT 6: ANALGESIA, SEDATION AND NEUROMUSCULAR BLOCKAGE  that’s why need time for family ANALGESIA...

Medical surgical 3 UNIT 6: ANALGESIA, SEDATION AND NEUROMUSCULAR BLOCKAGE  that’s why need time for family ANALGESIA members to provide access to give emotional support PAIN o Nursing Intervention or Procedure/ Physical manipulation (turning of patient and  described as an unpleasant sensory and emotional changing IV cannulas) experience associated with actual or potential tissue damage or described in terms of such damage. COMPONENTS OF PAIN o In critical care unit, the pain experienced by The experience of pain includes sensory, the patient is acute because it has an affective, cognitive, behavioral, and physiologic identified cause and it is expected to be components. resolved within the given time frame  Intervention: provide relief and 1. The sensory component is the perception of many promote comfort characteristics of pain, such as severity or intensity, o In critical illness, it is considered as painful location, and quality. and the elderly may suffer from both acute and chronic pain. For some, the pain is 2. The affective component includes negative continuous because it would persist for more emotions such as unpleasantness, anxiety, fear, than half each day. and anticipation that may be associated with the experience of pain.  the presence of pain may alter the ADL and personal relationship of the person.  Problem is the anticipation = “kung amuni ubrahon saakon basi masakitan Like trigeminal neuralgia = affects their ako” because px may have experienced manner of eating or combing their hair it in the past that’s why may anticipation  emphasizes the subjective and multidimensional 3. The cognitive component refers to the nature of pain. subjective characteristic implies that interpretation or the meaning of pain by the pain is whatever the person experiencing it says it is person who is experiencing it. and that it exists whenever he or she says it does.  Understanding of px about the pain  This definition also suggests that the patient is able 4. The behavioral component includes the strategies to self-report. However, in the critical care context, used by the person to express, avoid, or control many patients are unable to self-report their pain. pain.  There are multiple factors inherent in ICU’s 5. The physiologic component refers to nociception environment that would affect the pain experience of and the stress response. the patient, it could be related to: o Anxiety Types of Pain o sleep deprivation o unfamiliar environment/ unpleasant sound  noise = beeping of machines or Pain can be acute or chronic, with different noise of the healthcare providers sensations related to the origin of the pain.  lighting o loss of control over their situation 1. Acute Pain o separation from the family and significant others Acute pain has a short duration, and it usually corresponds to the healing process (30 days), Abby, meljun, kim Finals | Medical Surgical 3 1   Somatic pain involves superficial tissues, but should not exceed 6 months. such as the skin, muscles, joints, and bones. Its location is well defined. It implies tissue damage that is usually from an identifiable cause.  Visceral pain involves organs such as the heart, stomach, and liver. Its location is 2. Chronic pain diffuse, and it can be referred to a different location in the body. Chronic pain persists for more than 6 months after the healing process from the ○ px may have referred/radiating original injury, and it may or may not be pain associated with an illness. It develops when the healing process is incomplete or, as Neuropathic Pain described earlier, when acute pain is poorly managed. Neuropathic pain arises from a lesion or disease affecting the somatosensory system. A persistent type of pain that may interfere with ADLs and personal relationship The origin of neuropathic pain may be peripheral or central. Example: breakthrough pain of patients with cancer, continuous chronic pain and they It is a pathologic type of pain and would result from would experience acute exacerbation abnormal processing of sensory input by the periodically. Aside from cancer, patients with nervous system as a result of the damage to the peripheral neuropathies, neuralgia, peripheral or the central nervous system or both. osteoarthritis including the back or the neck pain after the injury was sustained by the  Neuropathic pain can be difficult to manage and patient. frequently requires a multimodal approach (i.e., the combinations of several pharmacologic and/or nonpharmacologic treatments). ❖ Both acute and chronic pain can have a nociceptive or neuropathic origin.  Central neuropathic pain involves the central somatosensory cortex and can be experienced by patients after a cerebral CLASSIFICATION OF PAIN BY INFERRED stroke. PATHOLOGY: Nociceptive Pain - Ex: Lesions within the spinal cord, patients with multiple sclerosis with ALS, stroke and Parkinson’s Disease Often a physiologic pain and refers to the normal functioning of physiologic system that would lead to  Peripheral neuropathic pain the perception of the noxious stimuli as being painful. - Ex: trigeminal neuralgia (patient may have a paroxysmal attack of pain and ○ Pain would start from the noxious stimuli patient may have the presence of pain either in the somatic or visceral organs can occur during simple activities and ○ Impulses are transmitted to spinal cord up to a hundred times per day up to the brain where action potential - Neuralgia and neuropathy are can occur examples related to peripheral neuropathic pain, which implies a  Describes the normal pain transmission damage of the peripheral somatosensory system. Nociceptive pain arises from activation of nociceptors, and it can be somatic or visceral. Abby, meljun, kim Finals | Medical Surgical 3 2  Physiology and Anatomy of Pain produced and is transmitted by nociceptive nerve fibers in the spinal cord that reach higher Nociception represents the neural processes of centers of the brain. encoding and processing noxious stimuli necessary, the stimuli would pass through the dorsal root of but not sufficient, for pain. the spinal cord wherein it would synapse in the Pain results from the integration of the pain-related dorsal horn of the spinal cord and the action signal into specific cortical areas of the brain potential is generated and the impulse would associated with higher mental processes and ascend up to the spinal cord until it would reach consciousness. In other words, pain is the conscious the brain. experience that emerges from nociception. The pleiotropic effects of pain are due to the 3. Modulation complicated processing of pain from stimulus to cerebral cortex. process by which noxious stimuli that travel from the nociceptive receptors to the CNS may be Physiology of pain = It is the process by which the enhanced or inhibited. person experiences pain occurs in four phases: Afferent pain signals are altered by efferent neural inhibition via neurotransmitters, especially There are four described elements of pain in the dorsal horn of the spinal cord or by processing: augmentation via neuronal plasticity (eg, central sensitization). 1. Transduction Neurotransmitters that enhances the painful It is the process wherein the noxious stimuli is stimulus: activated by the nociceptor located in the skin, Glutamate the subcutaneous tissue, and the visceral o Considered as the P neurotransmitter organs and also possibly related to the presence that promotes transmission of pain of nociceptors in the muscular skeletal structure. Neurokinins Noxious stimuli are converted to an action Substance P potential. Neurotransmitters that inhibit the painful Transduction refers to: mechanical (e.g., stimulus: surgical incision), thermal (e.g., burn), or Serotonin chemical (e.g., toxic substance) stimuli that norepinephrine damage tissues. In critical care, many nociceptive stimuli exist, 4. Perception. including the patients’ acute illness or condition, Integration of afferent pain signals in the invasive technology used for patients, and cerebral cortex. multiple interventions that have to be done for Pain message is transmitted by spinothalamic them. pathway to centers in the brain where it is These stimuli, also called stressors, stimulate perceived and is transmitted by the the liberation of many chemical substances, neospinothalamic tract and would reach the such as prostaglandins, bradykinin, serotonin, thalamus and transmitted by the histamine, glutamate, and substance P. These paleospinothalamic pathway that would reach neurotransmitters stimulate peripheral the brainstem, hypothalamus, and thalamus. nociceptive receptors and initiate nociceptive Result of neural activity associated with transmission. transmission of noxious stimuli that requires Noxious stimuli activates pain receptors in skin activation of higher brain structure for the or visceral organs -> noxious stimuli transmitted occurrence of awareness, emotions, and drives associated with pain 2. Transmission. Action potentials are conducted via afferent neurons (these are the neurons wherein it would carry the painful stimulus to the brain) As a result of transduction, an action potential is Abby, meljun, kim Finals | Medical Surgical 3 3  T: timing U: understanding observable or objective Behavioral Pain scale (BPS) Strategies for Pain Management  Techniques for appropriate pain management must be individualized to each patient, starting with an - greater than 5- presence of pain appropriate assessment of its severity.  If the patient is able to adequately communicate - Behavioral Pain Scale- combines pain, the following should be assessed: site, onset assessment of facial expression, upper and timing, quality, severity, exacerbating and limb movements and compliance with relieving factors, response to analgesics, and ventilation so is useful for assessing assessment of pain with movement, breathing, and pain in ventilated patient. cough.  Assessment or reassessment of pain exp especially Critical Care Pain Observation Tool (CPOT) if already given medications to manage pain = done every 30 mins to 1 hour - greater than 2- presence of pain (post- op pain) Assessment of Pain - indicated for patients in ICU who could not self-report the pain, difficulty in Pain assessment has two major components: communication, or not able to verbalize their pain whether or not they are non-observable or subjective / self-report intubated. (PQRSTU)  Fluctuations in vital signs should never be used Most reliable source of information (self-report) alone but rather considered as a cue to begin further The patient’s self-report of pain can also be assessment for pain. obtained by questioning the patient using the mnemonic PQRSTU: Patients who experienced pain during nociceptive procedures were three times more likely to have increased behavioral P: provocative and palliative or aggravating factors responses such as facial expressions, muscle rigidity, and vocalization than Q: quality patients without pain. Patients who experienced pain during R: region or location, radiation turning showed significantly more intense facial expressions (e.g., grimacing), muscle S: severity and other symptoms rigidity, and less compliance with the ventilator (e.g., fighting the ventilator) compared with patients without pain. Abby, meljun, kim Finals | Medical Surgical 3 4  Behavioral indicators are strongly assessment process of critically ill, sedated recommended for pain assessment in patients. The primary utility of the BIS is as an nonverbal patients. objective measure of sedation levels during surgery in the operating room or during  Nurses should observe whether pain is related to neuromuscular blocking in the critical care unit. any injury such as breathing (including artificial ventilation) or movement. Pain Management of Acute Pain Assessment tools: A. Pharmacologic pain management o Numerical scales (0-3, 0-10, which higher 1.) WHO analgesic ladder (Mild, mild to moderate, numbers indicating worst pain) moderate to severe)  Most common and px needs to understand that 10 is the highest o ‘faces’ or Wong Baker’s faces - originally (pediatric tools, but adopted for ICU) o Behavioral tools-was tested mostly in nonverbal mechanically ventilated patients with altered levels of consciousness  Changes in vital signs maybe caused by acute pain, but can also have other causes. Non-verbal cues can be reliable as verbal reports of pain. Sudden pain provokes a stress response with sudden: o Tachycardia+ shallow breathing o Hypertension o Tachypnea o Vasoconstriction (clammy, pale, peripheries) 2.) Opioids & NSAIDs o Sweating  remain the mainstay of acute pain management. Other non-verbal cues include:  Systemic opioids are traditionally the cornerstone of postoperative and critical care Facial grimacing- clenched teeth, wrinkled pain management. Opioids' sites of action affect forehead, biting lower lip, wide-open or tightly 3 of 4 pain-processing pathways. shut eyes.  Opioids act as ligands at G protein-coupled Position- double up, fetal position, ‘frozen’ or opioid receptors, namely, the μ (mu), δ (delta), maintained position for a long time, writhing and κ(kappa) receptors. These receptors are Pupil dilatation located peripherally, in the spinal cord dorsal horn as well as at various locations in the brain. Other Strategies:  Opioid receptors are located on primary afferent neurons and inhibit release of nociceptive Electroencephalogram-Continuous substances, decrease neurotransmitter release electroencephalographic (EEG) activity is in the spinal cord, and activate descending being used more frequently in critical care units, inhibitory neurons. especially in the brain-injured population, to detect epileptic activity and ischemia. NSAIDs Bi-spectral Index- Another innovative  Relieve pain by working peripherally at site of technology, the Bi-spectral Index (BIS), is being injury explored for its relevance in the pain Abby, meljun, kim Finals | Medical Surgical 3 5 3. Non- Opioids Analgesics/ Therapy 4. Adjuvant Therapy  Pain Management: enhanced by combination of  Drug that can assist in reducing certain types of opioid and nonopioid therapy pain  Provide indirect assistance to decrease other  Associated with fewer side effects than opioids symptoms and provide direct assistance as co- analgesic Acetaminophen is an analgesic used to treat  Generally used in addition to opioid and non- mild to moderate pain. It inhibits the synthesis of opioid analgesics neurotransmitter prostaglandins in the CNS, and  Examples of adjuvant drugs include: this is why it has no anti-inflammatory  Corticosteroids for cancer-related pain properties.  Antidepressants (Tricyclic Antidepressants or SNRI)  Use extra-precaution in its use for px  Anticonvulsants – DOC for peripheral with liver dysfx, malnutrition, and history neuropathic pain—trigeminal neuralgia of alcohol abuse (Gabapentin or Pregabalin)  Acetaminophen should not be greater  In the use of TCA than 4 grams in 24 hours to prevent  Need to assess px for adverse effects acetaminophen toxicity (sedation, dizziness, mental clouding, weight gain, constipation, hypotension, and cardio-toxicity Nonsteroidal Anti-inflammatory Drugs (NSAIDs). The use of NSAIDs in combination 5. Opioid Therapy with opioids is indicated in the patient with acute musculoskeletal and soft tissue inflammation.  First decisions: specific opioid drug, route of The mechanism of action of NSAIDs is to block administration (oral, rectal, intradermal, IM, IV, the action of cyclooxygenase (COX, which has PCA, SQ, Spinal) two forms: COX-1 and COX-2), the enzyme that  Next decisions: Suitable initial dose, frequency, converts arachidonic acid to prostaglandins. use of nonopioid analgesics  Indication: px with acute  Note: Dosing needs and analgesic response musculoskeletal and soft tissue vary greatly among patients inflammation  Common examples: aspirin, ibuprofen,  Factors to consider in determining naproxen, and ketorolac appropriate opioid analgesic therapy:  Ketorolac – most appropriate NSAID  Intensity of pain used in CCU but used with caution for  Age px with kidney dysfx and elderly  Coexisting disease Monitor for platelet and bleeding  Current drug regimen time (because it prevent platelet  Potential drug interaction of opioid with aggregation which could cause other drugs taken thrombocytopenia and can cause prolonged bleeding time) Some Opioids used as ICU analgesia: Morphine- remains the gold standard of opioid Another common medication used after IV therapy. It suppresses impulses from C fibers infusion of opioids but not A delta, so relieves dull, prolonged pain.  2nd generation NSAID (Celecoxib) –  Indicated for severe pain dilates post-op px, osteoarthritis peripheral veins and arteries reducing myocardial workload of px and treats anxiety of of px  Hydrophilic drug wherein slower onset of action Abby, meljun, kim Finals | Medical Surgical 3 6   Its relatively long effect makes bolus to be equivalent in action to morphine. administration feasible, which reduces Because the duration of action is short, problems from accumulation. dosing is frequent  At high doses in patients with kidney failure Diamorphine (heroin) is metabolized to or liver dysfunction or in older adult patients, morphine. it may induce CNS toxicity, including irritability, muscle spasticity, tremors, Fentanyl- twice as lipid- soluble as diamorphine, agitation, and seizures. so acts rapidly.  More potent than morphine, it does not Codeine has limited use in the management of cause histamine release, so causes less severe pain. It is rarely used in the critical care hypotension. Fentanyl derivatives unit. It provides analgesia for mild to moderate includes: alfentanil and remifentanil. pain. It is usually compounded with a nonopioid  Recommended: px with end organ (e.g., acetaminophen). failure, sever escalating pain (via IV), and long-term therapy and breakthrough  To be active, codeine must be pain metabolized in the liver to morphine. o Long term – Transdermal patch  Codeine is available only through oral, o Breakthrough pain – Oral, intramuscular, and subcutaneous transmucosal, and buccal route routes, and its absorption can be reduced in the critical care patient by 2 Derivatives of Fentanyl: altered gastrointestinal motility and decreased tissue perfusion.  Alfentanil- shorter duration (1-2) hours makes continuous infusion Dexmedetomidine (Precedex) is a short-acting safer; its metabolites are inactive, alpha 2 agonist that is indicated for the short- making it useful for patients with term sedation ( 24 hours of midazolam 6. bolus dose administration (for are discouraged because the drug has an active breakthrough pain). metabolite that may accumulate in the presence  A reasonable starting prescription in an opioid-naïve of drugs, renal disease, liver disease or old age. patient would be morphine with an incremental dose o Indication: acute short-term agitation of 1 to 2 mg, a lockout of 6 to 10 min, no continuous infusion rate, a 4-hour maximum dose of 30 mg, and  Propofol- is an IV general anesthetic designed a bolus dose of 2 to 4 mg every 5 min for 5 doses. for use as a continuous infusion. This drug ideas often preferred for short term sedation use (24hrs), its effect is more long term on a ventilator, and suffering from profound because awakening may take hours to days to hypoxemia.- sedation is needed. accomplish. Abby, meljun, kim Finals | Medical Surgical 3 11  Sedation scales  RAMSAY SEDATION SCALE: assess post- sedation consciousness  Allow the health-care team to select a level of sedation for the patient. Descriptors of each level of sedation are provided so that the sedative maybe adjusted appropriately.  is done at least hourly and the level of sedation achieved is recorded.  it is important for the interdisciplinary team to determine the level of sedation daily so the infusion rate can be adjusted accordingly. Drugs used for moderate sedation  Example: 1. Sedation-Agitation Scale a. Etomidate b. Propofol c. Ketamine d. Fentanyl e. Midazolam f. Diazepam g. Alfentanil Possible Complications of Moderate Sedation 1. Deep Sedation  Oversedation is recognized as a state of unintended patient unresponsiveness in which the patient resides in a state of suspended animation resembling general anesthesia. a) Possible complication of conscious sedation b) The nurse must be prepared to rescue a patient who progresses to deep sedation: 1. Manage a compromised airway 2. Provide ventilation 2. Richmond Agitation- Sedation Scale c) Placing a call to the Rapid Response Team  Prolonged deep sedation is associated with significant complications: immobility, including pressure ulcers, thromboemboli, gastric ileus, nosocomial pneumonia, and delayed weaning from mechanical ventilation Other possible complications a) Cardiopulmonary arrest b) Airway compromise c) Hypoxemia d) Aspiration e) Significant hypotension f) Significant brady-/tachycardia g) Prolonged sedation h) Death Abby, meljun, kim Finals | Medical Surgical 3 12  Delirium NEUROMUSCULAR BLOCKADE o is said to be present in 50% to 80% of critically ill patients.  Pharmacologic neuromuscular blockade (NMB) o Represent a global impairment of cognitive induces a state of physical paralysis. NMB is processes usually at sudden onset coupled with administered to achieve ventilator synchrony and disorientation, impaired short memory, altered improve oxygenation when this cannot be achieved sensory perception, abnormal thought by sedation and analgesia alone. processes, and inappropriate behavior  Because NMB causes a pharmacologic paralysis, o Patients are especially at risk if they are elderly, the patient will not be able to respond to verbal or have pre-existing dementia, hx of hypertension, physical stimuli and additional monitoring methods and high severity of illness at admission. are required. NMB is never administered unless o Can be r/t sedation or pain experienced of px adequate analgesia and sedation are also provided. This is because NMB paralyzes skeletal  Coma muscle but does not alleviate pain or confer o is an independent risk factor for the sedation. It is vital that measures are in place to development of delirium. avoid a scenario where a patient who has received o At greater risk: elderly, preexisting dementia, NMB cannot move, yet retains mental awareness. hypertension and high severity of illness during  Blocking release of acetylcholine (a admission neurotransmitter) at the neuromuscular junction  When patients are agitated, restless, and pulling at causes skeletal (but not smooth) muscle relaxation. tubes and lines, they are often identified as being Paralyzing agents may be classified as: delirious. In this scenario, delirium may be described o Depolarizing as “ICU psychosis” or “sundowner syndrome.” o Non-depolarizing However, the delirious patient is not always agitated, and it is much more difficult to detect delirium when Agents: the patient is physically calm. Provision of adequate analgesia is an essential component of delirium  Succinylcholine is the only depolarizing NMBD prevention. available in the United States—it depolarizes nicotinic acetylcholine receptors and either  SCCM guidelines recommend that routine desensitizes the receptor, inactivates sodium assessment of delirium be done with the use of a channels and prevents propagation of an action valid and reliable delirium- monitoring tool such aa potential, or a combination of both. CAM- ICU or Confusion Assessment Method for ICU  Mivacurium- is a rapid acting and has a short or ICDSC- Intensive Care Delirium screening duration of action (15 minutes). It may be given checklist as an IV bolus initially but then is provided by infusion.  Vecuronium- a steroidal-like agent is metabolized by the liver and excreted renally.  Combination of steroids and vecuronium may contribute to myopathies.  Pancuronium- is generally given by intermittent IV bolus.  It is vagolytic and can cause tachycardia; it maybe contraindicated in patients with cardiovascular disease and is metabolize by the liver and is renally excreted.  Most commonly used via IV bolus  Prepare antagonist at px bedside in case that px is using NMB agent Abby, meljun, kim Finals | Medical Surgical 3 13  Monitoring and Management Peripheral nerve stimulator (PNS)  are devices that deliver series of electrical stimuli via electrodes to nerves under the skin.  usually performed on the ulnar nerve at the wrist, with the temple area of the head is as another potential site for nerve stimulation. When electrical stimuli are applied for the ulnar nerve, the thumb abducts and the fingers flex if the neuromuscular junction is intact.  use to assess NMB is the train of four. Four small electrical stimuli are given every half second. 4 twitches neuromuscular blockade occupies px will can be  Focus especially in multiple victims = give upgraded to level if ECG revealed acute highest priority to px with highest chance of coronary syndrome survival  For px who aren’t salvageable and very obvious LEVEL II: URGENT CATEGORY: mortal wounds (crushing injury in the chest wherein death is imminent) are categorized as  Indicates that the victim should be treated quickly, level 3 except if there are adequate resources but that an immediate threat to life does not exist at the moment of evaluation. FOUR COLOR CODED TRIAGE SYSTEM: (CIVILIAN  These are clients who are seriously injured, may TRIAGE SYSTEM) die without further treatment. 0- BLACK DEAD o After reassessment, those in urgent CRITICAL OR LIFE THREATENING; category who have further deteriorated can 1- RED emergency treatment is initiated be upgraded to emergent category immediately and continued during  Include conditions such as: (emergent) transport.  Burns SERIOUS; can wait for transportation  major or multiple fractures after initial emergency treatment had  back injuries with or without spinal cord 2- YELLOW been given. damage.  Severe abdominal pain (urgent)  Renal colic High-risk but at the moment no life-  Displaced or multiple fracture threatening situation  Complex or multiple soft tissue injury MINIMAL; ambulatory, have minor  New onset of respiratory infection in elderly injuries, can be treated by non-  Temp greater than 38.3 °C 3- GREEN professionals and held for observation if necessary. LEVEL III: NONURGENT CATEGORY: (non-urgent)  Includes victim/s with noncritical injuries or minor Minor injury or minimal symptoms wounds, mortal wounds. o Mortal wounds – where death is imminent or certain FIVE-LEVEL TRIAGE  Include conditions such as:  Skin rash  Five-level triage severity rating system are used for o depending on manifestations (if with both emergency and routine health care breathing problems = level 1)  United States are the Emergency Severity Index o verbalized “skin rash because of (ESI) and Canadian Triage and Acuity Scale food allergy” = keep close (CTAS) monitoring o if no associated factors such as periorbital edema, thickening of lips, Abby, meljun, kim Finals | Medical Surgical 3 17   The ESI assigns patients into five levels, o acute mental status changes, or from level 1 (most urgent or emergent) to unresponsive. level 5 (least urgent).  Unresponsiveness is defined as a patient who is  With the ESI, patients are assigned to triage either: levels based on both their acuity and their 1. Nonverbal and not following commands anticipated resource needs. (acutely)  ESI (Emergency Severity Index) is a five-level 2. Requires noxious stimulus triage scale developed by ED physicians Richard Wuerz and David Eitel in the U. S. Four Levels of the AVPU Scale  Acuity is determined by the stability of vital A (Alert) – awake, responds to functions and the potential threat to life, limb, voice, and oriented of time, or organ. The triage nurse estimates resource place, and person needs based on previous experience with patients presenting with similar injuries or Triage nurse can obtain data complaints because responsive  Prioritization question: Who should be seen first? V (Verbal) – responds to verbal stimuli by opening eyes when Patient requires immediate life-saving ESI Level I: called and not fully oriented of intervention time, place, and person Patient is in High-Risk Situation, P (Painful) – only response to disoriented, severe pain, or vital signs painful stimulus; applied ESI Level II: in danger zone. peripherally (nail beds are pressed) If multiple resources are required to stabilize the patient but vital signs are If still no response, pinch px ESI Level III: not in the danger zone GENTLY If one resource is required to stabilize Best Noxious Stimulation = ESI Level IV: the patient and vitals signs are not in Sternal Rub GENTLY – to danger zone prevent tissue injury If patient does not require any U (Unresponsive) to both verbal ESI Level V: resources to be stabilized. and painful stimulus Examples of ESI Level 1 ESI LEVEL I:  Cardiac and Respiratory arrest  Lifesaving interventions are aimed at securing  Severe Respiratory distress an airway, maintaining breathing, supporting  O2 sat of less than 90% circulation, or addressing a major change in level  Critically injured px who presents of consciousness (LOC). unresponsive  Immediate lifesaving intervention required:  Overdose with RR = 6bpm only  Airway  Severe Respiratory distress with agonal  emergency medications, or other or gasping type of respiration hemodynamic interventions (such as IV  Severe Bradycardia/Tachycardia with insertion, supplemental oxygen therapy, signs of hypoperfusion cardiac monitoring, ECG, laboratories) and  Hypotension with signs of hypoperfusion any of the following clinical conditions:  Trauma px who require immediate crystalloids and colloidal resuscitation o intubated or needs intubation  Chest pain o apneic  Paleness o pulseless  Diaphoretic with systolic BP of 70 o severe respiratory distress palpatory o pulse oximetry (SpO2) < 90%  Weak and dizzy Abby, meljun, kim Finals | Medical Surgical 3 18   HR of 30bpm E. Several other general medical complaints  Anaphylactic shock o need to be considered for possible high-  Flaccid baby risk situations. These medical  Unresponsive px with strong odor of complications include the following: alcohol  Diabetic ketoacidosis  Hypoglycemia w/ mental status changes  Hyper- or hypoglycemia  Intubated px  Sepsis  Head bleed with unequal pupil  Complaints of syncope or near  Child who fell out from a tree and syncope became unresponsive to painful  A variety of other electrolyte stimulus disturbances ESI LEVEL II: F. mental health problems are at high risk o suicidal, homicidal, psychotic, violent, or  High risk situation: A patient you would put in present an elopement risk should be your last open bed. considered high-risk.  Severe pain/distress is determined by clinical o A danger to themselves, environment, or observation and/or patient rating of greater than or the healthcare professional equal to 7 on 0-10 pain scale o High-risk px – condition could easily G. severe headache associated with mental status deteriorate and present symptoms changes (decrease LOC, restlessness, confusion, suggestive of a condition requiring time- disorientation, somnolence), high blood pressure, sensitive treatment; px who has a lethargy, fevers, or a rash potential threat to life, limb, or organ H. sudden onset of speech deficits or motor High Risk Condition: weakness – might be manifesting symptoms of acute stroke A. Abdominal pain, Gastrointestinal- most frequent I. Females with abdominal pain or vaginal B. Chest pain - most common; chest pain alone bleeding o However, wherein px is physiologically o Should be assessed immediately and V/S unstable and requires immediate taken immediately intervention such as resuscitation, intubation o All pregnant patients with localized with hemodynamic support = level 1 abdominal pain, vaginal bleeding or o Episodic chest pain and epigastric discharge, 14 to 20 weeks and over discomfort with or w/o associated symptoms should be assigned ESI level 2 and seen = need ECG to determine ACS by a physician rapidly (according to individual institutional policy) C. Nose and Throat Patients who are drooling and/or exhibiting respiratory stridor may have J. Conditions that may be associated with some type impending airway loss. of visual loss include the following: o These are extremely high-risk patients.  Chemical splash o but if in RD = ESI level 1  Central retinal artery occlusion  Acute narrow-angle glaucoma D. Environmental  Retinal detachment o Patients with inhalation injuries from  Significant trauma closed space smoke inhalation or chemical exposure should be considered K. signs and symptoms of compartment high-risk for potential airway compromise. syndrome – high risk for extremity loss o Px with 3rd degree burns = either ESI 1 or ESI 2 depending on manifestations of px o Severe 3rd degree burns + smoke inhalation (inhalation injury) = at risk for severe RD Abby, meljun, kim Finals | Medical Surgical 3 19  L. Other patients with high-risk orthopedic then only upgraded after injuries – assessment/evaluation  any extremity injury with compromised neurovascular function P. Trauma  partial or complete amputation o Involve high-risk injury even may not be  trauma mechanism identified (serious immediately obvious = ESI 2 acceleration and deceleration injury of px) o If a trauma patient presents with unstable  possible gunshot vital signs and requires immediate  stab wounds intervention, the patient should be triaged as ESI level 1. M. high-risk situations for children:  Seizures Q. Wound Management  Severe sepsis, severe dehydration o These include uncontrolled bleeding,  Diabetic ketoacidosis arterial bleeding, and partial or full  Suspected child abuse amputations.  Burns  Head trauma R. Distress: the triage nurse must assess for severe  Ingestions and overdoses including distress, which is either physiological or vitamins psychological.  Infant less than 30 days of age with a fever of 38°C (100.4°F) or greater  Sickle cell crisis  Patients with severe psychological distress –  If child suspected of child abuse = need to be distraught after experiencing sexual assault, very careful; must inform social worker and local exhibiting behavioral outburst at triage, px who are police department combative or violent, victims of domestic violence,  Persons who brought child in hospital for acute grief reaction, and suicidal px = classified as suspected child abused must be interviewed by high-risk social worker and police officer  If px does not require detailed physical  If parents are the suspected abuser = during assessment or full set of vital signs = considered interview “wala gina pasulod” high risk  ESI level 1,2,4, and 5 = don’t need v/s except for N. mild-to-moderate distress should be further ESI level 3 wherein if there is a danger in V/S evaluated for respiratory rate and pulse oximetry categorized as level 3 and upgrade px to either to determine whether they should be categorized ESI 1 or 2 ESI level 2.  ESI level-2 patients remain a high priority, and o Patients in severe respiratory distress generally, placement and treatment should be who require immediate lifesaving initiated rapidly. intervention such as intubation meet  ESI level-2 patients are very ill and at high risk. level-1 criteria o O2 sat less than 90 with dec RR and gasping breathing = ESI level 1  V/S may not always be helpful in identification of o High risk px: currently ventilating with high-risk px oxygenation,  Emergency nurse can initiate care through o px with potential etiology of RR (asthma, standardized protocol without the physician COPD, pneumonia, pulmonary embolism, immediately at the bedside pleural effusion, pneumothorax, foreign  when the nurse recognizes that px needs body aspiration, toxic smoke inhalation, intervention but is confident that condition won’t and SOB with chest pain) = ESI level 2 deteriorate = can initiate intervention based on standardized protocol (such as IV access insertion, O. Toxicological administration of supplemental oxygen, obtain ECG o All types of poisoning of client, and placing px in cardiac monitor) before o Those who presents with overdose should physician would be present in emergency room be rapidly evaluated and they are high-risk Abby, meljun, kim Finals | Medical Surgical 3 20 Other examples of ESI Level 2 or high-risk  Temperature is specifically used in ESI triage for  active chest pain that does not require children under age 3. immediate life-saving interventions o Using the vital sign criteria, the triage nurse  a needle stick in a healthcare worker can upgrade an adult patient who presents  signs of stroke but not meet the level 1 criteria with a heart rate of 104, or this patient can  possible ectopic pregnancy but px is remain ESI level 3. hemodynamically stable o 6 months old baby with a cold and a RR of  px on chemotherapy with fever because 48 = either level 2 or level 3 immunocompromised  psychological disorders A Standardized Approach to Pediatric Triage Assessment ESI LEVEL III: Needs multiple Resource, VS not in danger zone  A general approach to pediatric triage is suggested:  To identify resource needs, the triage nurse must Appearance/work of breathing/circulation be familiar with emergency department standards Step 1 – quick assessment of care and must be knowledgeable of concepts of Airway/breathing/circulation/disability/expo prudent and customary Step 2 sure-environmental control (ABCDE)  Ask the question, given that the px cc or injury: Pertinent history Step 3 Which resources would the doctor would give to client? Step 4 Vital signs  Resources can be hospital services, tests, Step 5 Fever procedures, consults or interventions that are above and beyond the physician history and physical or very simple ED interventions such as applying a bandage. TO CONDUCT TRIAGE: PREHOSPITAL:  Only absolute requirement of the V/S are those 1. Move quickly from one victim to the next, complete who would meet the level 3 criteria a primary survey on each.  V/S assessment in the area are optional for ESI 2. Correct immediate life threatening problems. Apply levels 1, 2, 4, and 5 unless there are other ABC’s on a limited basis, depending on the personnel who could check the V/S availability of rescuers who can help with triage and treatment. DO NOT SPEND MORE THAN 30 Danger Zone Vital Signs – 60 SECONDS/VICTIM during the actual triage. 3. Tag each victim as to priority.  Danger Zone Vital Signs Consider up triage to 4. Ask for additional assistance if needed. ESI 2 if any vital sign criterion is exceeded.  Temperature is often used for children under the 5. Assign available manpower and equipment to age of 3 highest-priority victims.  Pediatric Fever Considerations 6. When additional help arrives, arrange for  1–28 days of age: Assign at least ESI 2 if treatment and transport of highest-priority victims temp > 38°C (100.4°F). first.  1–3 months of age: Consider assigning ESI 2 if temp > 38°C (100.4°F). 7. If possible, notify emergency personnel/hospital(s)  3 months–3 years of age: Consider of number and severity of injuries. assigning ESI 3 if temp > 39°C (102.2°F), 8. Triage rescuers remains at the scene to assign incomplete immunizations, or no obvious and coordinate manpower, supplies and vehicles. source of fever 9. Reassess victims regularly for changes in status.  Vital signs explicitly included in ESI triage include heart rate, respiratory rate, and oxygen saturation (for patients with potential respiratory compromise). Abby, meljun, kim Finals | Medical Surgical 3 21  NURSING PROCESS IN EMERGENCY SETTING: 1. CONDUCT A SCENE SIZE-UP:  the first priority when preparing to perform first  Same process in any other nursing setting aid. (Assess, Diagnose, Give Interventions,  Ensure your own safety, safety of the victim and Evaluate, and Reupgrade) bystanders at the scene.  Components of the nursing process is similar to  If not safe to go to the victim, call for help from those used in other settings. bystanders or barangay officials so they can  Several factors influence nursing process in contact appropriate agencies emergency care settings and includes the 5 COMPONENTS OF SCENE SIZE-UP: following: 1) Take body substance isolation precaution, if  Limited time frames. possible.  Urgency of the victim’s condition. 2) Assess the safety of the scene.  Possible need for definitive care in 3) Determine if the victim is injured or ill. another clinical setting. 4) Determine the number of victims.  Limited historic information. 5) Determine the resources needed.  Role and resources of the emergency care. 2. ESTABLISH RAPPORT:  identify yourself as a trained first aider/nurse  Often intervention occurs before complete  if not that confident even though you really want assessment is done or sometimes done to help the px, just activate EMS and stay with simultaneously with the assessment. the px. You can help by maintaining a patent  Nursing diagnoses is limited to those that can be airway but don’t do anything that may managed in the emergency setting. compromise px’s life 3 C’s: EMERGENCY ASSESSMENT:  Competence  Confidence  Assessment of the victim is one of the most  Compassion important and critical parts of first aid.  As you assess the victim, your main goal is to: ESTABLISH CONTROL: 1. Move smoothly and deliberately. 1. Protect yourself from injury 2. Position yourself at a comfortable level in 2. Identify and correct life-threatening relation to the victim. problem. 3. Keep your eye level above that of the victim. 3. Render proper first aid care. 4. Conduct your survey in an unhurried, 4. Prepare the victim for transport. systematic way. 5. Keep voice calm and quiet. VICTIM ASSESSMENT ROUTINE: 6. Perform triage if there is more than one victim. 1. Conduct a scene size-up. OBTAIN CONSENT: 2. Establish rapport and control.  IF VICTIM IS CONSCIOUS: can ask px so 3. Conduct a primary survey. identify yourself and ask if it’s ok to help. 4. Conduct a brief neurologic examination. Verbal consent of px is valid. = meaning nag 5. Determine the chief complaints. informed consent kay gin pamangkot gd 6. Assess vital signs  IMPLIED CONSENT: 7. Look for medical information devices. o Used for px requiring immediate 8. Take the SAMPLE history. intervention 9. Conduct a secondary survey o Based on assumption that unconscious px would give consent if the px was conscious Abby, meljun, kim Finals | Medical Surgical 3 22  o Covered by the good Samaritan law 3. CONDUCT A PRIMARY SURVEY: and even in the informed consent is  PRIMARY SURVEY: It is based on a standard still covered “ABC” with a “D” and “E” added for trauma o Good Samaritan Law clients.  limit the liability of the person  Check the ABC to provide quick who voluntarily performed assessment of the victim’s overall care and rescue in emergency condition. situation;  Limit to 30-60 sec/victim  provide protection from claims of negligence for those who A - AIRWAY/SPINE STABILIZATION: provided care without expectations of payment i. Highest priority in primary survey is to  responder must not receive establish an open airway. monetary compensation from ii. ALWAYS ASSUME SPINAL DAMAGE – px or family unconscious victim. iii. IF CONSCIOUS/ TALKING: visually scan  IF VICTIM/ GUARDIAN REFUSES TO the general appearance, cyanosis and CONSENT: you may not give first aid or sweating. transport forcibly the victim. Law iv. If airway is not open: do the HEAD- enforcement officer are the only person who TILT/CHIN LIFT MANEUVER or can touch, restrain or transport someone MODIFIED JAW THRUST if spine injury is against their will. suspected.  Establish manual in-line spine stabilization  FOR MINORS: right to give consent are the  According to American Heart Association in guardians or parents Emergency Situation, if the airway of px is not open then proceed first to breathing and leave  IF VICTIM IS UNCONSCIOUS AND on how to open airway INVOLVE A LIFE-THREATENING SITUATION – do first aid and transport even B – BREATHING: without consent.  Determines whether or not ventilatory effort is KINDS OF CONSENT: efffective  The focus is on auscultation of breath sounds  Actual consent: and evaluation of chest expansion, respiratory informed consent, explain the care you effort and any evidence of chest trauma or will provide; oral consent is valid. physical abnormalities.  IF RESPONSIVE – client is typically breathing spontaneously.  Implied consent:  IF WITH ALTERED MENTAL STATUS: if victim is unconscious, the law  LOOK for chest rise and fall assumes that he or she would consent  LISTEN for air movement at the mouth to care if conscious. and nose  FEEL on your cheek for air passing and out of the mouth or nose  Minor’s consent:  IF NOT BREATHING SPONTANEOUSLY OR the right to give consent by parents or ADEQUATELY: begin artificial breathing guardian of a minor. immediately. -> then proceed to letter C or Circulation  IF BREATHING ADEQUATELY: continue with primary survey. Abby, meljun, kim Finals | Medical Surgical 3 23   IF SPINAL INJURY IS SUSPECTED: keep the C – CIRCULATION: victim in supine position maintaining the head and neck in a neutral-in-line position.  Focus is the adequacy of HR of px; check for  HEAD IS IN NEUTRAL IN-LINE POSITION: pulsation if present = ok to take BP nose is in-line with trachea and umbilicus of px  If pulseless = Start with CAB (Compression, Airway, Breathing) E – EXPOSURE:  If px is CONSCIOUS = check the radial pulse; IF UNCONSCIOUS or radial pulse can’t be felt,  Final component of the primary survey check the carotid pulse.  Remove all clothing as necessary – allow for  IF NOT BREATHING, PULSELESS and thorough assessment UNRESPONSIVE within 10secs– START CPR.  If px is exposed, maintain privacy o If one responder = give 30 chest compressions (placed px in on a flat surface in a supine position), push hard 4. CONDUCT A BRIEF NEUROLOGIC and fast that is greater than 100/min and EXAMINATION: allow for full chest recoil o After chest compression, go to airway and  Can use AVPU scale to assess the mental open using head-tilt chin lift method or status, motor function, sensory function of the modified jaw-thrust technique and give client. rescue breathing  Follow the steps:  IF BREATHING and with PULSE – continue by checking for serious or profuse bleeding. 1. Talk to the victim st o after 1 cycle of CAB, check the pulse and 2. Note the speech if still pulseless and breathless proceed to 3. If victim can’t talk, determine whether the 2nd cycle victim can understand by assessing o if 2 responders – 15:2 ratio of chest response to simple command. compressions and rescue breathing 4. If with altered mental status – determine  IF WITH MAJOR BLEEDING – control to how easily can the victim be aroused, prevent tissue hypoperfusion by: o Apply direct pressure over the bleeding  IF DO NOT RESPOND to voice – try to wound stimulate by painful stimulus. o Elevate part of the body if applicable above level of heart  If spinal injury is suspected – tell the victim to o Apply direct pressure over the artery near lie still, stabilize spine, activate EMS the wound (Emergency Medical Services) system. o LAST RESORT: apply torniquet only as necessary o once resources are available = can insert SHOUT/CALL FOR HELP or ACTIVATE EMS IV catheter of large gauge 16 or 18 for SYSTEM: if applicable. fluid resuscitation o Access site (excellent initial approach for Give the following information when activating EMS: critically ill when veins can’t be accessed) 1. Exact location of the victim = intraosseous access 2. The phone number where you can be reached. 3. Any information about the victim that will help the D – DISABILITY: rescuer send appropriate personnel and equipment.  Provides a rapid baseline assessment of the neurologic status of the client.  if possible – send a responsible bystander to  Use AVPU scale the telephone with the above information  IF WITH ALTERED MENTAL STATUS: place  IF ALONE: client in lateral recumbent position. Abby, meljun, kim Finals | Medical Surgical 3 24   for adult - activate EMS immediately 8. TAKE A “SAMPLE” HISTORY: after you determine unresponsiveness  for unconscious infant or child –  S – signs and symptoms provide 1 minute rescue support/ CPR  A – Allergy before activating the EMS system.  M – Medication  IF NO telephone is available – continue giving  P – Past Medical History first aid care until a bystander is available to  L – Last Meal (very important esp if injuries activate the EMS system. sustained needs surgery or anesthesia)  E – Events prior to incident 5. DETERMINE THE CHIEF COMPLAINTS: 9. CONDUCT A SECONDARY SURVEY:  Even if px is alert, even the injury is obvious –  Conduct closer look with the px once life- need to ask concern of px threatening condition have been controlled and  Ask: “tell me where you hurt” – the answer is v/s are recorded. the chief complaint.  Comprehensive head-to-toe assessment to identify other possible injuries or medical issues 6. ASSESS VITAL SIGNS: that needs to be managed that might affect the course of the treatment  Vital signs should be taken repeatedly at 2-5  Conduct a full body assessment by inspection minutes intervals. with your hands to check for swelling,  Changes in vital signs reflect both changes in depression, deformity, bleeding, or other the victim’s condition and effectiveness of first problems aid care.  Explain to the victim as well as significant other  Use SENSES – sight, touch, and hearing – to If present what you are doing and keep talking determine pulse, respiration, temperature and calmly throughout the survey. color of the victim’s skin.  Keep the head and neck alignment and DON’T  PULSE – if conscious: radial; move the victim unnecessarily until you have if unconscious: carotid pulse finished the survey and ruled out the possibility if conscious then fainted and you haven’t of spinal injuries. finish checking pulse = from radial just shift to carotid pulse USE THE FOLLOWING APPROACH:  RESPIRATION – note for cardinal signs of LOOK respiratory distress (nasal flaring, use of Deformities, wound, bleeding, discoloration, accessory muscles, retractions in supra-, intra- penetration, openings in the neck and unusual clavicular area, intercostal spaces) chest movement LISTEN  TEMPERATURE/ SKIN COLOR – assess by placing the back of the hand against the skin of Unusual breath sounds, gurgling sounds or the victim’s neck or forehead; note skin color; crepitus capillary refill FEEL 7. LOOK FOR MEDICAL INFORMATION DEVICES Unusual masses, swelling, hardness, stiffness, mushiness, muscle spasms, pulsation,  such as IDs, medic alert tag, necklace or tenderness, deformities, and temperature bracelet. SMELL Unusual odor in victim’s breath, body, or clothing In cases of poisoning where px has taken substances = may have unusual breath odor Abby, meljun, kim Finals | Medical Surgical 3 25 ASSESS FOR SIGNS/SYMPTOMS OF PRIORITY NURSING INTERVENTIONS: INJURY:”DOTS” 1. Airway patency (as necessary with spinal  D – Deformity immobilization also)  O – Open wound/s  T – Tenderness 2. Supplemental oxygenation – initiate at 6 – 10  S – Swelling L/minute. 3. Spinal precautions and immobilization. (Suspected for spinal injury = move or turn px as  protect PRIVACY of victim a single unit)  only cut clothing if necessary 4. CPR  After secondary survey – care for any injuries as 5. Brief neurologic examination time allows.  Extent of secondary survey and first aid care 6. Psychological support of the needs of the victim would depend on how quickly EMS arrives. and significant others. 7. Discharge planning. PRINCIPLES OF MANAGEMENT: would serve as guidelines when giving first aid care:  If px don’t want to be admitted, IMPORTANT INSTRUCTION: if there is 1. Remain calm and think before you act. a new onset of a symptom or progression in px manifestations must 2. Identify oneself as a nurse to the victim and seek consultation in the nearest bystanders. emergency department 3. Do a rapid assessment for priority data (such as  Discharge planning is done once px is cessation of breathing or heat beat). admitted and possible discharge 4. Carryout life saving measures as indicated by the CARDINAL RULE OF INTERVENTION: “DO NOT FURTHER HARM” priority assessment data. 5. Do a head-to-toe assessment before initiating general first aid measures. 6. Keep the victim lying down or in the position in which he or she is found (unless orthopnea is present), protect from dampness by covering px with towels or any available resources 7. If victim is conscious, explain what is occurring – assure the victim that help will be given. 8. Avoid unnecessary handling or moving of the victim, move the victim ONLY if danger is imminent. 9. Do not give fluids per orem if there is possibility of abdominal injury or if anesthesia will be necessary within a short of time. 10. Do not transport victim until first aid measure have been carried out and appropriate transportation is available. Abby, meljun, kim Finals | Medical Surgical 3 26  Airway Obstruction  assess the Oral Care needs of the  Acute upper airway obstruction is a life- patient who is at risk of inspissated threatening medical emergency. secretions o Wherein airflow is interrupted through the  poor oral hygiene would lead to the nose, the mouth, the pharynx or the larynx of thickening and the hardening of the patient secretion that may lead to the possible  leading cause of accidental death for children under complete obstruction of the airway so 14 years old and is the most common cause of the patient would be at risk for the respiratory emergency however it's not only common development of altered mental status, among children but also common among adults dehydration, no verbal output or inability  This is a frightening experience for the patient and of the patient to communicate because would require Prompt Care to prevent the partial of the presence of that thick and crusty obstruction from progressing into a complete secretion and inability of the patient to obstruction of the airway cough effectively thereby preventing the  Partial obstruction of the airway can lead to patient to expel the thick and crusty progressive hypoxia, hypercarbia, and respiratory secretion. and cardiac arrest. o Occlusion of the airway by the tongue of the Common causes of acute upper Airway obstruction: patient  especially when the patient is unconscious or in o presence of the foreign body (either be food or coma or it is related to the loss of pharyngeal small objects especially for small children and also muscle tone or it could be related to the loss of fluids including saliva, thick secretion as well as the the gag reflex of the patient blood vomitus  if the patient is unconscious after determining the responsiveness- need to open the airway if it  the foreign body obstruction would occur most is necessary because that could be the reason frequently in children below 9 years old and the why the patient goes into unconsciousness symptoms may vary widely and may be delayed depending on the degree of the obstruction o Tongue edema because it could be partial or it could be  is related to surgery or trauma or angioedema complete obstruction of the airway as a result of an anaphylactic reaction or  foreign body obstruction would be an acute anaphylaxis onset of absence of breathing or acute onset of respiratory distress related to the o Smoke inhalation obstruction of the airways of the patient  may also cause mucosal edema of the airway  but both either partial or complete obstruction of that could cause lower airway obstruction the airway may lead to severe hypoxia leading to unconsciousness with possible death of o Peritonsillar and pharyngeal abscess or infection patient when the condition is not intervened  may cause the mucosal edema immediately  because of this complete obstruction then it may o Facial, tracheal or laryngeal trauma lead to the possible death of the patient wherein the patient can go into unconsciousness or o Head and neck cancer or throat cancer coma, respiratory arrest and cardiac arrest because of this obstruction o Burns of the head or of the neck area  One preventable type of obstruction especially  resulting to mucosal edema for patients admitted in the hospital is the inspissated oral or nasopharyngeal secretion o For patients with a head or neck cancer or - this is a thick and crusty secretion that could be cancer of the throat together with patients with found in the nose or mouth of the patient infection and peritonsillar or pharyngeal abscess because of failure to do the oral hygiene and  the onset of obstruction would be a gradual failure of the nurse to clean the nose of the manifestation of respiratory distress patient Abby, meljun, kim Finals | Medical Surgical 3 27 o Anaphylaxis Clinical Manifestations  the patient may manifest dyspnea, wheezing,  The airway may be partially or completely occluded. muffled voice or stridor.  If the airway is completely obstructed, permanent  together with possibility of angioedema as a brain damage or death will occur within 3 to 5 result of anaphylaxis minutes secondary to hypoxia. o oxygen saturation of the blood decreases rapidly because of the obstruction of the Pathophysiology airway preventing the entry of air into the lungs of the patient and oxygen deficit may also occur in the brain resulting into unconsciousness followed by the death of the patient o the patient ma