High Acuity and Emergency Situations PDF

High Acuity and Emergency Situations Foreign Body Obstruction Foreign body airway obstruction a partial or complete blockage of the breathing tubes to the lungs due to a foreign body (for example, food, a bead, toy, etc.). The onset of respiratory distress may be sudden with cough. There is...

High Acuity and Emergency Situations Foreign Body Obstruction Foreign body airway obstruction a partial or complete blockage of the breathing tubes to the lungs due to a foreign body (for example, food, a bead, toy, etc.). The onset of respiratory distress may be sudden with cough. There is often agitation in the early stage of airway obstruction is a clinical emergency that may be life threatening. Nurses should be confident to assess the severity of airway obstruction, deliver interventions to relieve that obstruction and know when to call for assistance. Cause of obstruction: Improper chewing of large pieces of food Excessive intake of alcohol The presence of loose upper and lower dentures For children: running while eating For smaller children of “hand-to-mouth” stage left unattended 2 types of obstruction: 1. Anatomical obstruction- when tongue drops back and obstructs the throat. Other causes are acute asthma, croup, diphtheria, swelling, and cough (whooping) 2. Mechanical obstruction- when foreign objects lodged in the pharynx or airways; fluids accumulate in the back of the throat Classification of obstruction: 1. Mild obstruction- the victim is responsive and can cough forcefully, although frequently there is wheezing between coughs 2. Severe obstruction- the victim has a weak, ineffective cough, high-pitched noise while inhaling, increased respiratory difficulty, and possible cyanosis. The victim is unable to speak, breathe, or cough and may clutch the neck with thumb and fingers. Movement of air is absent The following procedures follow the Resuscitation Council’s guideline on the management of choking in infants (1 year). An algorithm provides quick guidance on the appropriate procedure. Prevention of choking in infants and children Nurses should advise parents to: Always cut up food: infants and young children can choke on small, sticky or slippery foods Keep small objects out of reach: infants and small children examine objects by putting them in their mouths. Ensure small toys/objects such as building bricks, button batteries, coins and marbles are stored out of reach Sit children down to eat Always supervise infants and young children Mild airway obstruction (effective cough) in infants and children Coughing generates high and sustained airway pressures, and may expel a foreign body, so it is important to encourage the child to cough. Children with an effective cough will be able to cry or verbally respond to questions. In these situations, no external maneuvers – such as back blows – are needed but close observation is required until the infant/child improves, as severe airway obstruction may develop. Severe airway obstruction (ineffective cough) in infants (1 year) If a child shows signs of severe airway obstruction: Call for help immediately; Deliver up to five back blows (slaps): ○ Position the child with their head down (a small child may be placed over the lap). If this is not feasible, support the child into the leaning-forward position recommended for adults ; ○ Deliver up to five sharp back blows (slaps) with the heel of one hand in the middle of the back between the shoulder blades. Following each back blow, check to see whether the obstruction has been dislodged. If back blows fail to dislodge the object and the child is still conscious, deliver up to five abdominal thrusts using the following procedure: Position yourself behind the child either standing or kneeling. Place your arms under the child’s arms; Place a clenched fist between the umbilicus and xiphisternum; Hold the clenched fist with your other hand; pull sharply inwards and upwards; Deliver up to five abdominal thrusts. Following each abdominal thrust, check to see whether the obstruction has been dislodged; Take care not to apply pressure to the xiphoid process or the lower rib cage as this may cause abdominal trauma; If the obstruction remains, continue alternating up to five back blows with up to five abdominal thrusts. Management of the unconscious infant/child If the infant/child loses consciousness: Carefully support them to a flat surface; Summon help if it is still not available (do not leave the infant/child); Open the infant’s/child’s mouth. If an obvious object is seen, attempt to remove it with a single finger sweep. Blind or repeated finger sweeps are not recommended because the object could be pushed deeper into the pharynx; Open the airway and attempt five ventilations. Determine the effectiveness of each ventilation – if the chest fails to rise, reposition the head; If the infant/child remains unresponsive, commence chest compressions immediately. It is advised for a lone rescuer to perform cardiopulmonary resuscitation for one minute before summoning assistance; Before repeating ventilations, check the mouth for the presence of an object and remove it if this is possible Aftercare After successful treatment for a FBAO, the foreign body may still be present in the airways and can cause complications. Advise parents/carers that they should seek medical advice if the infant/child has dysphagia or a persistent cough, or complains of having something stuck in their throat. As chest/abdominal thrusts and chest compressions can cause serious internal injury, patients must be examined for injuries after these interventions have been performed (Perkins et al, 2017). Professional responsibilities – These procedures should be undertaken only after approved training, supervised practice and competency assessment, and carried out in accordance with local policies and protocols. Treatment of FBAO in adults The Resuscitation Council’s (2017) adult choking algorithm provides guidance on the treatment of choking in adults. If FBAO is suspected, it is important to assess its severity and always ask the patient “are you choking?”. Their response will help distinguish between a mild or severe obstructive airway Severity of airway obstruction Mild airway obstruction (effective cough): patient able to talk and has an effective cough Severe airway obstruction (ineffective cough): typically, patient responds “yes” by nodding their head without speaking; unable to cough effectively Mild airway obstruction (effective cough) Coughing generates high and sustained airway pressures and may expel a foreign body, so it is important to encourage the patient to cough. A patient with mild airway obstruction should remain under continuous observation until they improve as a severe obstruction may subsequently develop Aggressive treatment with back blows and chest and abdominal thrusts at this stage is unnecessary – it may cause harm and could exacerbate the airway obstruction. These interventions should only be used if the patient shows signs of severe airway obstruction Severe airway obstruction (ineffective cough) If the patient shows signs of severe airway obstruction: Call for help immediately and encourage the patient to cough; Stand at the patient’s side, slightly behind them; Support the patient’s chest with one hand and lean them forward – if this dislodges the foreign body, it will hopefully fall out of the mouth instead of slipping further down the airway; If symptoms continue, deliver up to five back blows (slaps) between the scapulae using the heel of the hand. Following each back blow, check to see if the obstruction has been dislodged  If the back blows fail, proceed to abdominal thrusts; Stand behind the patient, placing both arms around the upper abdomen; Lean the patient forward; Place a clenched fist between the patient’s umbilicus and the ribcage, and clasp it with the other hand; Deliver up to five sharp thrusts to the abdomen, inwards and upwards; Take care not to apply pressure to the xiphoid process or the lower ribcage as this may cause abdominal trauma; If the obstruction remains, alternate up to five back blows with up to five abdominal thrusts. If the patient loses consciousness you should: Carefully support them to the ground; If you have not done so already, summon help following local protocols – call for an ambulance or contact your cardiac arrest team; Start cardiopulmonary resuscitation (CPR) – do 30 chest compressions first as these may relieve the obstruction; After 30 compressions, attempt two ventilations, then continue CPR until the patient recovers and starts to breathe normally (Perkins et al, 2017). Abdominal thrusts in an obese or pregnant patient It may be difficult to carry out abdominal thrusts on a patient who is obese or pregnant. If you cannot encircle their abdomen, stand behind the patient, position your hands over the lower end of the sternum and pull hard into the chest with quick thrusts (chest thrusts) Aftercare and referral for medical review Following successful treatment for an FBAO, a foreign body may still be present in the airways; if someone has dysphagia, a persistent cough or complains of having something stuck in their throat, they should seek medical advice. Performing abdominal thrusts and chest compressions has the potential to cause serious internal injury, including ruptures or laceration of abdominal or thoracic viscera, so patients must be examined for injuries. Use of airway clearance devices Although there are several airway clearing devices for the treatment of FBAO currently available, their routine use is not recommended by the Resuscitation Council (UK). However, appropriately trained health professionals can use advanced techniques – such as suction or laryngoscopy and forceps – to remove a foreign body from the airway Injuries to the Head, Spine, and Face The brain is a soft and delicate organ. A hard blow to the head can injure the brain or spinal cord even when there are no visible signs of trauma to the scalp or face. That’s why all head injuries are considered serious and should be assessed by your doctor or the nearest hospital emergency department. Two types of head injury Head injuries can be classified as: Open – with bleeding wounds to the face or head Closed – no visible signs of injury to the face or head. Closed head injuries The soft, jelly-like brain is protected by the skull. The brain doesn’t fill the skull entirely – it floats in a clear, nourishing liquid called cerebrospinal fluid. This fluid acts as a shock absorber, but its protective value is limited. The kinetic energy of a small knock to the head or face can be absorbed by the cerebrospinal fluid, but a hard impact can smash the brain against the inside of the skull. This can bruise the brain or tear blood vessels. If blood and blood serum start to escape, the swelling is contained within the skull. Intracranial pressure (pressure inside the skull) can cause permanent damage by literally crushing the brain. Symptoms of a head injury Blood is not a reliable indicator of the seriousness of a head injury. Apart from wounds, other symptoms of serious head injury can include: Altered consciousness – for example, the person may lose consciousness for short or longer periods or may be conscious again, but confused or drowsy. They may even have a brief seizure. They may also change by improving for a while and deteriorating again later. Skull deformities – compressions or deformities are signs of fractures. Clear fluid from the ears or nose – a skull fracture, especially a fracture to the base of the skull, can allow cerebrospinal fluid to leak from the ears or nose.  Black eyes and bruised skin behind the ears – this indicates that the force of the blow was sufficient to rupture blood vessels around the eyes and ears. Vision changes – the pupils of the eyes may be dilated (enlarged) and be different sizes in a person with a serious head injury. The person may complain of double or blurred vision. Nausea and vomiting – these are common side effects of serious head injury and should always be considered important if they persist. First aid when the injured person is conscious Encourage the injured person to minimise any movement of their head or neck. Scalp injuries can bleed profusely, so control any significant blood loss from head wounds with direct pressure and a dressing. While examining the wound, avoid disturbing blood clots forming in the hair. Reassure the person and try to keep them calm. First aid when the injured person is unconscious The person should not be moved unless they are in immediate danger. Any unnecessary movement may cause greater complications to the head injury itself, the spine or other associated injuries. A good rule is that if the head is injured, the neck may be injured too. Your role is to protect the injured person from any potential dangers at the scene. You should also monitor their airway and breathing until the arrival of an ambulance. If the person’s breathing becomes impaired due to a problem with their airway, you may need to very carefully tilt their head back (and support it) until normal breathing returns. If the person stops breathing or has no pulse, cardiopulmonary resuscitation (CPR) may be required. Treatment of concussion Concussion is a mild traumatic brain injury that follows some trauma to the head. It is a diagnosis made by a doctor when it is certain a more serious head injury has not occurred. Symptoms of concussion can persist for up to three weeks after trauma. Your doctor or hospital will provide advice for yourself and your family regarding your ongoing care when being discharged for home. Most importantly, be alert for any danger signs over the next one or two days, such as persistent vomiting, loss of coordination, or bad or worsening headaches despite analgesia (pain-relieving medication). Seek medical attention immediately. Facial trauma or maxillofacial injuries refer to those occurring to the mouth, face, and jaw. These types of injuries are commonly encountered in emergency rooms as a result of assault and accidents related to driving vehicles, industrial work and sports. Studies have shown that close to a half million emergency department visits each year are related to facial trauma. Facial injuries can interfere with a patient's ability to eat, speak, breathe, listen, see, and to perform other important routine sensory and physiological functions. A facial fracture is a broken bone in the face. The face has a complex bone structure. The facial skeleton consists of the: Frontal bone (forehead). Zygomas (cheekbones). Orbital bones (eye sockets). Nasal bones. Maxillary bones (upper jaw). Mandible (lower jaw). What causes facial fractures? You can break the bones in your face in many ways, including: High-impact accidents, such as motor vehicle accidents. Sports injuries. Workplace accidents. Falls. Interpersonal trauma like fighting or domestic violence. What are the symptoms of a facial fracture? Symptoms of a fracture to the face may include pain as well as bruising, swelling or tenderness. Symptoms of a nose fracture may include: Purplish patch on skin caused when blood leaks from broken blood vessels (also called bruising or ecchymosis). Discoloration under the eyes (“black eyes”). Blockage of one or both nostrils or a deviated septum. Twisted or crooked nose or indented bridge. Nosebleed. Symptoms of an orbital fracture may include: Blurry, decreased or double vision (diplopia). Difficulty in moving eyes left, right, up or down. Swollen forehead or cheek or swelling under the eyes. Flatness of the cheeks. Sunken or bulging eyeballs. Facial numbness near the injury. Blood or discoloration in the white part of the eye. Symptoms of upper or lower jaw fractures: Trouble with chewing, eating, or speaking. Loose, broken or missing teeth. Teeth not fitting together properly. Cheek pain when opening the mouth 1. Determine priorities of care a. Maintain airway, breathing, and circulation b. Provide supplemental oxygen as indicated c. Establish intravenous (IV) access for administration of crystalloid fluid/blood products/medications as needed d. Obtain and set up equipment and supplies e. Prepare for/assist with medical interventions f. Administer pharmacologic therapy as ordered 2. Relieve anxiety/apprehension 3. Allow significant others to remain with patient if supportive 4. Educate patient and significant others Protocol for airway management in maxillofacial trauma Anticipate and recognize an airway obstruction Clear the airway, position the patient. Perform chin lift and jaw thrust maneuver Confirm the nasal and oral aperture are clear then use artificial airways and Perform bag-valve-mask ventilation. Preferably “two-person technique” Endotracheal intubation In unsuccessful orotracheal intubation or “cannot ventilate can't intubate situation” perform surgical airway (cricothyroidotomy or tracheotomy under local anesthesia is a lifesaving procedure in selected patients in the “cannot intubate, cannot ventilate” situation ) spinal cord injury (SCI) is damage to any part of the spinal cord or nerves at the end of the spinal canal. The condition often causes permanent changes in strength, sensation, and other body functions below the site of the injury. Motor vehicle accidents, acts of violence, and sporting injuries are the common causes of spinal cord injury (SCI). The mechanism of injury influences the type of SCI and the degree of neurological deficit. Spinal cord lesions are classified as a complete (total loss of sensation and voluntary motor function) or incomplete (mixed loss of sensation and voluntary motor function). Physical findings vary, depending on the level of injury, degree of spinal shock, and phase and degree of recovery, but in general, are classified as follows: C-1 to C-3: Tetraplegia with total loss of muscular/respiratory function. C-4 to C-5: Tetraplegia with impairment, reduced pulmonary capacity, complete dependency for ADLs. C-6 to C-7: Tetraplegia with some arm/hand movement allowing some independence in ADLs. C-7 to T-1: Tetraplegia with limited use of thumb/fingers, increasing independence. T-2 to L-1: Paraplegia with intact arm function and varying function of intercostal and abdominal muscles. L-1 to L-2 or below: Mixed motor-sensory loss; bowel and bladder dysfunction. Signs and symptoms of spinal injuries may include: Body lying in an awkward, unnatural position Skin feeling clammy and cool Inability to move limbs. Flaccid paralysis below level of injury Loss of spinal reflexes below level of injury Loss of sensation (pain, touch, proprioception, temperature) below level of injury Loss of sweating below level of injury Loss of sphincter tone and bowel & bladder dysfunction Diagnostic tests: X-ray CT scan MRI Myelography Toddlers and head injuries Toddlers fall over all the time. Parents should note that: A fall from the child’s own height usually isn’t enough to cause a serious head injury The size of a bump on the head has no connection with the severity of injury Minor head injuries, like a bump on the head, can be treated with cuddles and an age- appropriate dose of children’s pain-relieving syrup. Medical attention should be sought immediately if the child shows any signs of serious head injury, particularly if they are unusually drowsy or vomiting, if you think the fall was heavy enough to have caused harm or if the child appeared to be unconscious or did not immediately cry after the fall. Examples of a heavy fall are falling down some stairs, rolling from a normal height change table to a hard floor, falling from a bed to a hard surface or a head strike on bedside furniture. If in doubt, see the doctor.  Initial care - immobilization: ○ Immobilize the entire spine of any patient with known or potential SCI ○ Immobilize neck with a hard collar. ○ Use log roll with adequate personnel to turn patient while maintaining spine alignment ○ For children < 8 years of age use an airway pad to promote neutral cervical spine position ○ Remove from spinal board on arrival in ED or as soon as resuscitation allows ○ Maintain neck in neutral position by use of a hard collar, but change to two- piece collar for comfort and avoidance of complications (e.g. pressure area, venous obstruction, aspiration) within 6 hours of admission. Airway with cervical spine protection Early and safe airway management in the SCI patient can make a crucial impact to long--‐ term patient outcomes and functional deficits. Assess for airway stability Attempt to gather a response from the patient. Look for signs of airway obstruction (use of accessory muscles, paradoxical chest movements and see-saw respirations). Listen for any upper-airway noises and breath sounds. Are they absent, diminished or noisy? Spinal patients are at particular risk of passive regurgitation and subsequent aspiration. High cervical injuries potentiate loss or compromise of both gag and cough responses. (Nasogastric tube insertion is highly recommended although consideration of intubation and inherent airway protection should be considered prior to insertion.) Attempt simple airway manoeuvres if required Open the airway using a chin lift or jaw thrust. Suction the airway if excessive secretions are noted or if the patient is unable to clear it themselves. Insert an oropharyngeal airway (OPA)/nasopharyngeal airway (NPA) if required. Secure the airway if necessary (treat airway obstruction as a medical emergency) Consider early intubation if there are any signs of: decreased level of consciousness, unprotected airway, an uncooperative/combative patient leading to distress and further risk of injury pending airway obstruction: stridor, hoarse voice apnoea or respiratory failure due to paralysis. Intubation of the patient while maintaining full spinal precautions requires skill and a high level of teamwork. Maneuvers to open the airway that mobilise the cervical spine, such as a neck tilt are contraindicated. Only jaw thrust and chin lift should be utilised. Manual in-line cervical stabilisation must be maintained while the cervical collar is removed to facilitate intubation. A second assistant may apply cricoid pressure over the cricoid cartilage ring while intubation is performed. The use of external laryngeal Assess the chest Assess the patient’s ventilation by monitoring their respiratory rate and oxygen saturation. Auscultate to identify abnormal breath sounds and assess their bilateral air entry Circulation with haemorrhage control Intravenous access should be obtained early to permit fluid administration. Management of volume resuscitation is important in spinal patients and hypotension should be avoided; a general guide is to maintain a systolic blood pressure of above 90 mmHg. It is important not to assume that hypotension in a patient with SCI is solely as a result of their cord injury without excluding other causes such as haemorrhage. Inspect for any signs of haemorrhage and apply direct pressure to any external wounds. Consider the potential for significant internal bleeding related to the mechanism of injury, which may lead to signs and symptoms of shock. Expect hypotension and bradycardia associated with spinal shock in those with lesions above the sixth thoracic vertebrae. Additionally, neurogenic shock may cause a bradycardia, contributing to hypotension, and may require treatment with medication such as atropine. Disability: neurological status Perform an initial AVPU assessment (Alert, responds to Voice, responds to Pain, Unresponsive); check the patient’s pupillary response. Until ruled out by appropriately qualified clinical personnel with supportive radiological examination, all trauma patients should be assumed to have a spinal injury until proven otherwise. Identifying a cervical spinal injury in primary assessment is important. Priapism, diaphragmatic breathing and loss of anal tone are key signs of high spinal cord compromise. Combative patients should not be physically restrained due to the increase in leverage and potential for further injury. Sedation, intubation and ventilation may be indicated to manage severe agitation. Exposure/environmental control Remove the patient’s clothing to allow a complete examination. An SCI patient can become hypothermic due to the loss of autonomic regulation, so it is important to monitor their temperature and keep them in a warm environment. Secondary survey The secondary survey is only to be commenced once the primary survey has been completed and any life-threatening injuries have been treated. If during the examination any deterioration is detected, go back and reassess the primary survey. History Taking an adequate history from the patient, bystanders and emergency personnel of the events surrounding the injury can assist with understanding the extent of the injury, and any possible other injuries. Use the AMPLE acronym to assist with gathering pertinent information: A Allergies M Medication P Past medical history including tetanus status L Last meal E Events leading to injury Neurological assessment Neurological assessment and documentation in the EMR including: ○ Sensory level ○ Motor function After 72 hours, completed documenting sensory and motor levels. Contact the rehabilitation registrar to assist with this assessment ○ Glasgow coma score ○ Pupil response Perform hourly for 1st 24 hours then decrease to 4 hourly if condition stabilised Note evidence of brain injury as well as spinal cord injury Vital signs (and autonomic control) Vital signs can be quite abnormal following SCI. In addition to the usual causes in trauma such as pain, bleeding and distress, this can be due to loss of autonomic control, which occurs particularly in cervical or high thoracic injuries. The autonomic nervous system controls our HR, BP temperature etc. Autonomic instability is most acute in the first few days to weeks of the injury. Particular implications of autonomic instability to be aware of are: Heart rate Bradycardia can easily occur , for example on endotracheal tube or tracheostomy suction, due to unopposed vagal activity (Thoracic sympathetic input may have been damaged) Patient needs continuous HR monitoring in PICU or ward Treatment with anticholinergic medication is often required Blood pressure Loss of autonomic control results in loss of vasomotor tone. Patient may be quite vasodilated and hypotensive. This phase of neurogenic shock can last up to several weeks. Hypotension should be treated to prevent secondary poor perfusion of the spinal cord. Blood pressure monitoring should be: ○ Continuous in ICU ○ At least hourly in the ward Ensure patient is adequately fluid resuscitated but not overloaded Patient may need vasopressor drugs such as nor-adrenaline or intravenous fluids to maintain BP (but excessive fluids will cause pulmonary oedema). Patients requiring vasopressors should be managed in PICU Temperature The loss of temperature control e.g. ability to sweat, shiver, vasodilate, vasoconstrict or position self to maintain temperature. Consequently, the child will take on the temperature of the environment Hypothermia is common Temperature measurement should be performed 4hrly in the acute stage of admission Ensure adequate clothing or bedding in cool environment Ensure artificial cooling in a hot environment Potential complications and management The following are the most common complications seen for these children. The prevention and management is described above under the relevant headings Pressure sores Autonomic Hyperreflexia (Dysreflexia) Pneumonia and retained secretions Urinary tract infections Constipation Deep venous thrombosis Bone demineralisation/ hypercalcaemia Latex allergy Spasticity – deformities/pain