TRAUMA CARE-MS DIDA.pdf

TRAUMA AND EMERGENCY CARE A period of apnea is intentionally instituted to prevent forcing air into the stomach via positive-pressu...

TRAUMA AND EMERGENCY CARE A period of apnea is intentionally instituted to prevent forcing air into the stomach via positive-pressure ventilation, which would increase intragastric pressure and potentiate regurgitation and aspiration. During a normal intubation, at least one attempt is made at controlled positive- pressure mask ventilation (test breath) between the administration of the anesthetic induction agent and the neuromuscular- blocking agent. This ventilation provides the health care provider with the knowledge that RAPID SEQUENCE INTUBATION the patient can be mask-ventilated in case ✓ An aspirated volume as small as 25 mL may intubation attempts are not successful. have disastrous consequences. RSI does not allow for this ventilatory check, which increases the risk for hypoxia in the Securing the airway by intubating the trachea is apneic patient. Thus, the major risk involved an essential component of the resuscitation in performing an RSI is the inability to process in the emergency department for patients ventilate the patient in case intubation fails. with compromised airways or ventilatory failure. Reasons to RSI Reasons not to RSI Rapid sequence intubation (RSI) is a specialized Rapid achievement of Difficult airway form of placing an endotracheal tube (ETT) in a unconsciousness is anticipated patient to provide ventilation via a secure airway. required Patients in respiratory distress or those unable to Rapid achievement of Difficult face mask intubating conditions is ventilation anticipated maintain a patent airway often require the required placement of an ETT to allow some form of Rapid airway securing Dangerous technique if assisted or controlled ventilation. in high risk conditions is emergency surgical required airway is not possible When the potential for gastric content eg. Neck trauma/tumour regurgitation exists, an RSI is used to reduce the Can reduce the risk of Team members not risk of aspiration. An RSI is designed to ensure regurgitation skilled in assisting eg. that no gastric contents are aspirated into the Providing cricoid tracheal tree, which could result in pneumonia or Useful in the setting you Hostile environment are working in eg. Out and some equipment not acute respiratory distress syndrome (ARDS). of hospital or wards available CLINICAL TECHNIQUE ✓ Assembly of all required equipment is essential before attempting any intubation. RSI differs from normal intubations in several key ✓ Suction must always be available to remove ways. Similar to all intubations, the patient secretions, blood, and regurgitated materials should first be preoxygenated to fill the functional from the oropharynx. residual capacity (FRC) with 100% oxygen. ✓ One or more laryngoscope handles with However, unlike standard intubation procedure, charged batteries and at least two RSI calls for the use of the Sellick maneuver laryngoscope blades (Miller 2 and Macintosh 3 (cricoid pressure) while the patient is induced are recommended), as well as multiple sizes of with anesthetic medications. Once induced, the ETTs should be at the bedside. patient with RSI is not ventilated before ✓ At least one ETT should have a semirigid administering neuromuscular-blocking agents or stylet inserted. A method for delivering before attempting direct laryngoscopy. positive-pressure ventilation must be at hand 1  before intubating the patient (e.g., bag-valve- mask). ✓ A patent intravenous (IV) line is imperative, and all appropriate medications should be immediately available. Common Endotracheal Tube Sizes Age and Sex Appropriate Most Depth of Sizes Common Insertion as Size Measured at Teeth Children Age + 16/4 Variable Age + 10 cm (age = 4+4 Adult men 7.5 to 8.5 8.0 23 cm Adult women 6.5 to 7.5 7.0 21 cm MANY DISEASE STATES CAN SIGNIFICANTLY ALTER BOTH THE PHYSICAL AMOUNT OF THE FRC AND THE AMOUNT OF TIME THE BODY TAKES TO USE THIS OXYGEN RESERVE. If the patient is alert and cooperative, then 30 mL COMMON MEDICATIONS USED IN RAPID of sodium citrate (Bicitra) can be administered to SEQUENCE INTUBATION decrease stomach acidity. If time permits, 50 mg of IV ranitidine (Zantac), 20 mg famotidine (Pepcid), or 10 mg of IV metoclopramide (Reglan) may be administered to decrease regurgitation and aspiration. Since most RSIs are attempted in emergent conditions, this precludes premedications. Preoxygenation is recommended before attempting intubation. Despite differences in how preoxygenation is performed, its use is universal. Preoxygenation allows the patient's Functional Residual Capacity (FRC) to be filled with oxygen. FRC is that portion of the total lung volume that is not normally expired during spontaneous ventilation. By filling these areas of the lung with oxygen, the patient is provided with a small reserve of oxygen. In a young, healthy man, filling the FRC with 100% oxygen allows up to a 5- to 7- 2  minute reserve of oxygen if the patient Suction should always be available when becomes apneic. intubating a patient. Significantly, the aduration of apnea caused An acronym that has been used to aid those by an induction dose of succinylcholine applying cricoid pressure is B-U-R-P. (Anectine) (1.0 to 1.5 mg/kg) is close to 5 to 7 minutes. Both obesity and pregnancy can B stands for backward or posterior significantly reduce the physical volume of the displacement. FRC, whereas tachycardia, sepsis, and other U stands for a slightly upward or cephalad hyperdynamic states cause a more rapid use of movement. the oxygen in the FRC. Additionally, both R stands for a slight right displacement of obesity and pregnancy increase the cephalad the larynx. movement of the diaphragm on induction of P stands for the pressure used to occlude anesthesia, further decreasing the FRC the esophagus. considerably. The person assisting with the intubation must Vital capacity is defined as a maximum correctly identify the cricoid cartilage before inspiration immediately after a maximum applying pressure. From the prominence of the expiration. Adam's apple(thyroid cartilage), the nurse slides the fingers down the anterior aspect of the When the oropharynx is filled with blood, patient's neck until the first depression is felt, secretions, or foreign material, these should be which marks the cricothyroid membrane. The suctioned and an attempt should be made at next cartilage ring is the cricoid cartilage. preoxygenation in all but the direst situations. Pressure is applied by the use of the thumb and Unconscious and trauma patients who have first two fingers on opposite sides of the cricoid lost their normal protective airway reflexes cartilage. The assistant's hand should not be on and who are not spontaneously ventilating the larynx or thyroid cartilage. pose a unique problem. Any positive-pressure breaths administered via a bag-valve- mask TO APPLY CRICOID PRESSURE, REMEMBER increase the chances for regurgitation and B-U-R-P: aspiration of gastric contents. In such cases, BACKWARD many practitioners choose to skip UPWARD (SLIGHT) preoxygenation and establish a controlled RIGHT DISPLACEMENT airway via immediate tracheal intubation. (SLIGHT) The next distinguishing technique in RSI is PRESSURE TO OCCLUDE THE the use of cricoid pressure or the Sellick ESOPHAGUS maneuver. The cricoid cartilage is the first The application of cricoid pressure does have tracheal cartilage ring below the larynx. More risks. Complications range from interference importantly, the cricoid cartilage is the only with tracheal intubation, to esophageal continuous cartilaginous ring below the rupture, to fracturing the cricoid cartilage. larynx. Practitioners are split in their opinions of the Application of pressure (from 0.5 to 8.0 lb/ft) to best time to apply cricoid pressure. Slight this cartilage ring results in compression of pressure may be applied before administering the esophagus, which lies immediately any medications, increasing the pressure as posterior to the trachea. Firm pressure helps the patient loses consciousness. prevent the chances of gastric content Alternatively, cricoid pressure may be applied regurgitation, but excessive pressure can just as or immediately after the patient loses actually hinder intubation. consciousness. 3 Do not remove cricoid pressure until intubation different laryngoscope blade may be used, or has been successful. the patient's airway may need to be As previously stated, an RSI does not allow for repositioned. a test-breath ventilation after the patient is The ability to secure a patent airway in an induced. Once preoxygenation is completed emergency depends on being prepared. A and cricoid pressure is applied, an appropriate feared complication of rapid sequence induction drug is administered, which is intubation is the inability to intubate and followed by a neuromuscular-blocking agent. subsequently ventilate the patient. Personnel Succinylcholine (Anectine) is the "gold and equipment preparation are essential standard" for RSI because of its rapid onset components in the management of a failed and short duration of action. intubation. Essential equipment should be However, succinylcholine causes an increase stored in the resuscitation area and be clearly in serum potassium levels of up to 0.5 to 1.0 identified as "difficult airway" equipment. The mEq/L, making it contraindicated in patients immediate availability of the following items with, most notably, burns and neurologic is imperative: disorders. STANDARD INTUBATING EQUIPMENT A long-acting neuromuscular-blocking agent ✓ Laryngoscope handles with functioning light should be administered with extreme caution and source in consideration of the potential consequences. ✓ Multiple laryngoscope blades (Macintosh 3 or Unconscious patients may be safely intubated 4/Miller 2 or 3) without the use of a neuromuscular-blocking ✓ Oral endotracheal tubes or various sizes (5.0 agent. In emergency situations and in some to 8.0 mm) elective intubations requiring RSI in which ✓ Stylet succinylcholine (Anectine) is or may be ✓ Ambu-bag with mask contraindicated, the use of etomidate ✓ Oxygen source (Amidate) can allow successful intubation without the risks involved with the ✓ Suction, suction catheter, and Yankauer tip nondepolarizing neuromuscular-blocking ✓ Induction and paralytic medications agents. ✓ Stethoscope A key benefit of etomidate (Amidate) is that many patients continue to ventilate Alternative airway equipment should be kept spontaneously, even after receiving an available in case an intubation should become induction dose. Before deciding to skip difficult: paralyzation, the person performing an RSI should assess the need for some form of muscle Minimum Essential Equipment relaxation. Patients with tightly clenched jaws ✓ Laryngeal mask airways (LMAS) may not be able to be intubated without some ✓ Airways (nasal and oral) form of pharmacologic relaxation. ✓ Tube exchangers (bougies) Meticulous attention to detail, including the ✓ Tracheostomy tubes proper labeling of the medications used in the ✓ Needle cricothyroidotomy induction and intubation of patients, is essential. ✓ Lighted stylet Up to 40% of emergent intubations are ✓ Fiberoptic bronchoscope unsuccessful on the first attempt. Any The nurse's role may also involve moving the repeated attempts at intubation require some patient and applying cricoid pressure. change in technique or current situation. The If the professional performing the intubation oropharynx may require deep suctioning, a uses a flexible stylet in the ETT, then he or she 4  may ask the nurse to remove the stylet once brain to tolerate increases in intracranial the ETT is past the vocal cords. volume without adversely increasing ICP. Only the stylet should be grasped and removed. Too vigorous removal or grasping the ETT may result in accidental extubation. FIRST-LINE AND INITIAL TREATMENT FOR RSI Preoxygenate the patient (may be omitted if airway reflexes are lost or foreign material is observed in the oropharynx). The Monro-Kellie hypothesis states that the Apply cricoid pressure. skull acts as a closed, rigid vault containing Administer medications (induction without the intracranial components of brain tissue ventilation). (84%), blood (4%), and CSF (12%) under which Provide intubation. the total brain volume remains fixed. When Check placement of ETT. any one of the three components increases in Release cricoid pressure volume, another must decrease to maintain the overall volume. INCREASED INTRACRANIAL PRESSURE CSF delivers oxygen to the tissues in the brain and maintains cerebral perfusion through the compensatory mechanism of autoregulation. When changes in the blood pressure (BP) occur, cerebral blood vessels automatically constrict or dilate to maintain perfusion and deliver oxygen to the tissues. Autoregulation is maintained with a mean arterial pressure (MAP) of 50 to 70 mm Hg. CPP is defined as a pressure gradient across the brain and is the difference between the arterial blood entering and the return of venous blood exiting the neurovascular Intracranial pressure (ICP) is a dynamic state system. It is viewed as an estimated pressure that reflects the pressure of cerebrospinal fluid and is calculated as the difference between the (CSF) within the skull. Increased ICP is described incoming MAP and the opposing ICP on the as pressures ≥ 20 mm Hg. arteries, which is affected by the ability of the Adults and older children: 60 mm Hg monitoring brain tissue oxygen (PbtO2) have been instituted. Hypoxia at the brain tissue level has TRAUMATIC BRAIN INJURY been linked to poor outcomes, so monitoring efforts are being aimed at early detection and Traumatic brain injury (TBI) is a collective term intervention to prevent secondary brain injury. describing a wide range of pathologic conditions and types of trauma involving the brain. Brain tissue oxygen is monitored by inserting a catheter into the white matter of the brain, and TBI occurs when a substantial force-which can be the catheter is connected to a device calibrated to blunt, penetrating, or a combination of the two- measure brain tissue oxygenation. Another useful strikes the skull. The result is a brain injury. technique for measuring cerebral oxygenation is TBI is one of the leading causes of trauma death, jugular venous oxygen saturation (SjvO2) and is responsible for nearly 50% of the 150,000 monitoring, which is performed through a injury related deaths in the United States yearly. fiberoptic catheter positioned in the bulb of the jugular vein. ositive end-expiratory pressure Not only is TBI the most lethal of all trauma- (PEEP) should be used with caution because it can related injuries, but its survivors also suffer the decrease venous drainage and outflow, which greatest disability with long-term effects and increases ICP and CPP. Monitoring and deficits. maintaining BP within desired limits is critical to maintaining ICP, CPP, and CBF. The mechanism of injury (MOI) or the extent of the injury-its effects and survivability-has many 8 factors and is ultimately unique to each individual A backward fall that is significant enough to patient. cause a fracture to the skull usually involves the occiput, which is a basal skull fracture. Initial assessment may be deceiving. For example, These fractures can involve a shifting of bone in the patient with a closed- head injury, brain articulations (e.g., break away or opening of damage may not be obvious because of an absence the occipitosphenoidal fissure). of external blood. These fractures are not usually life The contributory causes of TBI are threatening but may disrupt the meningeal customarily associated with motor vehicle layers and allow leakage of CSF and blood accidents (MVAs), sports injuries, falls, and from the ears and nose. A closer assessment violence. Head trauma occurs when the finding of a basal skull fracture includes generated force is greater than the cranial ecchymosis at the site of the mastoid process vault can absorb, transferring the kinetic (battle signs) or around the periorbital area injury to the delicate neural tissues beneath. (raccoon eyes) or both. Understanding the basic anatomy, physiology, types of injury, and effects of trauma on the BASAL SKULL FRACTURES brain, as well as the rapid recognition of these These fractures occur in the bones behind the signs and symptoms, is imperative in treating dotted line that surround and protect the brain. patients with brain trauma. These bones are extremely strong and are broken Even a basic comprehension of TBI and its only in cases of severe trauma. mechanisms can assist in the delivery of ✓ Symptoms of skull fractures include quality nursing care. The study and unconsciousness, amnesia, headaches, blurred management of the central nervous system vision and paralysis. (CNS) can be intimidating and complex; ✓ In severe cases, there may be a discharge from however, it can be easily learned with the the nose and ears. knowledge of a few simple facts and treatment Raccoon eyes is a sign of basal skull fracture. principles. FIVE MAJOR TYPES OF PRIMARY TBI HAVE BEEN ESTABLISHED: 1) SKULL FRACTURES, 2) CONCUSSION, 3) CONTUSION, 4) DIFFUSE AXONAL INJURY (DAI), AND 5) HEMATOMA A. SKULL FX When a patient suffers a skull fracture, approximately two out of every three patients acquire a mild-to-severe brain injury. A single This injury often exposes the brain to the blunt strike, which usually fractures along a exterior environment with disruption of the fissure line in the cranium, is called a linear cribriform plate, which is a small, thin bone fracture. that is separated by tissue in the nasal cavity. The linear fracture is most common, The patient with this type of fracture is at risk accounting for 75% to 80% of all skull for encephalitis and meningitis. fractures. The linear fracture is highly Another type of cranial bone injury is a associated with subdural and epidural bleeds. depressed skull fracture, which may cause contusion or laceration to the brain tissue. If a 9  fracture with a perforated scalp is observed, The MOI is similar to that of a concussion but then it is an open fracture. The patient with more severe. When the tissue damage occurs this type of fracture is also at risk for directly at the site of impact, it is categorized developing an infection. as a coup (coo) injury. The disruption of bones can damage brain A more involved contusion is often a result of tissue, vessels, and cranial nerves as they pass an acceleration-deceleration event. This MOI through the skull, requiring diligent and causes the brain to shift rapidly and strike one ongoing neurologic assessments. side and then the opposing side of the cranium, causing lesions in two areas of the brain, B. CONCUSSION known as a coupcontrecoup injury. The edema and extent of the bleeding from a The cerebral contusion is most often seen in contusion are an immediate clinical concern. temporal and frontal lobes of the brain. The A concussion is a direct brain injury involving contusion produces tissue edema and capillary neural tissue (neural parenchyma); it is hemorrhage. generally mild but may have underlying pathologic consequences such as slow subdural bleed that is not observed until days after the injury. The MOI involving concussion is usually associated with a blunt trauma from a blow to the head or from a fall. The injury is traditionally diagnosed by the patient's manifestation of symptoms because obvious physical injury is not always present. In cases of concussion, a complete recovery usually occurs; however, many patients suffer amnesia involving events surrounding the trauma. In moderate-to-severe concussions, the symptoms may include a loss of consciousness, a diminished or complete loss of deep tendon D. DIFFUSE AXONAL INJURY reflexes (DTRs), and an apneic episode in some (DAI) patients. The energy absorbed through the → Diffuse axonal injury (DAI) describes cranium is believed to stun the brain to the extensive damage involving a wide area of point of momentarily ceasing neurologic neural tissues throughout the cerebrum and function; similar to the use of a defibrillator on brainstem. the myocardium. Up to this point, the injuries discussed primarily involved localized lesions in the C. CONTUSION outer neural gray matter. Diffuse axonal Contusions occur when the head suffers a direct injury refers to damage that involves the impact with a rigid object. innermost centroaxial areas of the neural white matter. COUP-CONTRECOUP INJURIES These injuries disrupt the neural network fibers and tracts that facilitate communication → Damage may occur directly under the site of among the brainstem, cerebellum, and impact (COUP), or it may occur on the side hemispheres of the cerebrum. opposite the impact (CONTRECOUP). 10  This type of injury is associated with MOI symptoms include increased drowsiness, involving mechanical sheering forces confusion, and nonlocalizing headache directly generated by an MVA or other similar events. related to the increase of ICP. A minor head Diffuse axonal injuries occur in approximately injury can initially cause similar signs and one-half of all trauma-related comas and are symptoms observed in the subdural bleed. responsible for long-term neural deficits in the recovering patient with a TBI. An epidural hematoma is an arterial bleed and develops quickly; a subdural hematoma is a The degree and progression of the injury requires venous bleed and develops slowly. close monitoring and frequent neurologic testing Other traumatic intracranial hematomas that to track the onset of subtle changes in neurologic may occur include bleeding into the ventricles, status that indicate increased ICP. subarachnoid space, and superior sagittal sinus. Any of these bleeds can occur together and may involve any combination of the previously mentioned TBIS. Patients with intracranial hemorrhage quickly lose their ability to physiologically compensate, and this development can occur with less than 100 mL of blood. A catastrophic brain injury is a severe injury in which the cranium is exposed to extraordinary force involving MVCs, falls from significant Е. НЕМАТOMAS heights, mechanical crushing, and missile An epidural hematoma_develops under the penetration. The brain's direct or indirect arterial pressure of the bleed, which tears the absorption of this momentous kinetic energy (KE) periosteal layer (a part of the dura mater) from lacerates or tears the parenchymal tissue, causing the cranium as the hematoma expands, a disruption of the meninges, neural tissue, nerve resulting in the compression of brain tissue. tracts, and blood vessels. A TBI caused by a The symptoms may involve a rapid onset of projectile that forcefully enters the cranium neurologic signs, or the patient may remain creates a cavitation that displaces tissue in the lucid many hours after the TBI and then brain, delivering direct and extensive damage as suddenly deteriorate. An epidural hematoma it travels through the cranium and possibly exits is an emergency condition that requires the the skull. This patient often has a terminal hematoma to be drained quickly to prevent prognosis; if only the brain is involved, the patient permanent brain damage. becomes a prime candidate for organ donation. A subdural hematoma is an intracranial venous bleed involving the space between the dura meningeal layer and the arachnoid layer. A subdural hematoma often involves the bridging veins that transverse the dura mater, occurring commonly on the lateral aspects of the hemispheres of the cerebrum. Subdural hematomas expand as a result of venous bleeding (low pressure bleed), and the onset of symptoms are slow in developing- beginning from as early as 48 hours to as long as 2 weeks after head injury. Characteristic 11  causing the accumulation of cellular toxins and decreasing the autoregulation ability. Once the blood flow to the brain becomes compromised, the brain tissue does not receive oxygen or essential nutrients (e.g., glucose) that are carried in the blood, resulting in further injury. A late sign of severe cerebral ischemia is the Cushing response, a feedback mechanism that attempts to reduce the ischemia by increasing CBF. If the rising ICP is not treated, death ultimately occurs as the brainstem herniates through the foramen magnum, ceasing all cardiopulmonary function and causing brain death. Understanding the intracranial perfusion principles is of paramount importance in managing complications caused by TBI. When acutely impaired patients arrive in the emergency department or trauma center, basic standardized steps are initiated. Without a uniform approach, patients with horrific wounds can easily distract care team members and crucial resuscitative steps can Formula for Estimating ICH Hematoma Volume be omitted. AxBxC The operational tenet of the ABC algorithm is 2 to "keep it simple," which allows the care team to function in an orchestrated manner during Select CT slice with largest ICH stressful, time-sensitive events involving TBI. A = longest axis (cm) The first and most important step is airway B = longest axis perpendicular to A (cm) evaluation. C= # of slices x slice thickness (cm) Patients with extensive brain injury usually arrive at the hospital via the emergency Estimated volume of spheroid medical service (EMS), often with initial Correlates well w/ planimetric CT analysis airway measures accomplished. In TBI cases, other than obvious foreign body SECONDARY BRAIN INJURIES obstruction or traumatic injury to the oral A secondary brain injury consists of neurologic pharynx, an accepted threshold for initiating tissue damage that occurs after the initial RSI is based on the patient's GCS score injury and increases the morbidity and (usually GCS < 8) and the patient's inability to mortality of the patient, a result of the brain's protect his or her airway. Adhering to cervical reduced ability to maintain a homeostatic spine precautions at all times is imperative environment. because of the increased risk of cervical spine Most often, MAP, CBF, ICP, and CPP are fracture, which is four to six times more likely adversely affected. As the symptoms and in a patient with a TBI. As the assessment damage progress, hypoventilation and begins, key questions are asked to treat and hypoperfusion states lead to acid-base issues, anticipate the immediate needs of the patient. 12 When evaluating the respiratory status of a Rate and depth of Consider intubation, if not patient with a TBI, hypoxia along with the TBI respirations already intubated. Maintain can further increase the ICP, decreasing both Saturations normocapnia (PaCO2 of 35 mm (pulse oximeter > Hg); may require MAP and CBF and further injuring the brain by 97%) hyperventilation of patient. increasing ischemia. Aggressive hyperventilation Satisfactory Elevate head of the bed if not is not recommended; however, maintaining a arterial contraindicated. PaCO2 of approximately 35 mm Hg should be the blood gas results therapeutic goal for ventilation management. If a nasogastric (NG) tube is needed, extreme caution must be taken during placement. An ASSESSMENT QUESTION 1 undiagnosed skull fracture could allow the NG IS THE PATIENT'S GCS SCORE AT 9 OR tube to perforate the parenchyma of the brain. ABOVE? Yes No The identification of low BP and rapid reversal of Use Prepare to implement RSI protocol. this deficit provides positive outcomes in supplemental Intubate. managing TBI. oxygen. Securely fasten ETT. Continue Set up appropriate oxygen delivery ASSESSMENT QUESTION 3 assessment. system. Limit ETT movement IS THE PATIENT'S SYSTOLIC BLOOD (manipulation can irritate the PRESSURE (SBP) ABOVE 90 MM HG, AND ARE vagus nerve and therefore increase THERE STRONG PERIPHERAL PULSES? ICP). Yes No Suction equipment available Obtain 1 or 2 IV Obtain two large-bore (16- (increased ICP can cause projectile sites (preferably gauge) IV sites; may need to emesis and posttraumatic 18-gauge). assist in central line placement seizures). Continue if one is not in existance. assessment. Prepare to deliver crystalloid The degree of injury and the brain's ability to Await fluid and rapidly or other colloid IV fluids. compensate are reflected in the circulatory medication Obtain rapid fluid infuser. system's response. Assessing the patient's orders. Closely monitor cardiovascular status. circulatory status involves distinguishing the Anticipate the use of emergency rate, rhythm, and intensity of the pulse. Next, medications. assess for secondary signs of hypoxia, such as cool, Place urinary catheter. clammy skin and cyanosis of the nail beds and oral Closely monitor fluid status membranes. Treating hypotension is a priority (intake and output). over other interventions for the brain injury: Problems must be corrected early to maintain The early hours after brain injury, intervention is CBF and CPP. Hemodynamic monitoring critical but the at the same time the brain is protocols must be initiated and therapeutic fragile and vulnerable. During this time modalities need to be used to help keep the continuous monitoring of vital signs and the patient's circulation within normal or acceptable neurologic status an essential task for the nurse. parameters. The ABCs(airway, breathing, circulation) of ASSESSMENT QUESTION 2 trauma resuscitation are the primary life-saving IS THE PATIENT ABLE TO VENTILATE measures used in stabilizing the patient, but D for ADEQUATELY WITH A SPONTANEOUS disability is the treatment step that collectively REGULAR RATE AND EFFORT? takes the brain injury into account. Yes No Continue Assist with breathing (high-flow This step incorporates ABC management to help assessment: oxygen and airway delivery reduce secondary brain injury and thus improves systems). the patient's chance of recovery. 13 The "tools of the trade" are used to obtain a Components of Neurologic Assessment Mental baseline neurologic examination to help Status determine the primary injury, anticipate urgent Level of consciousness (GCS score) care needs, and further monitor the stabilization Orientation (time, person, place) process. In addition, the nurse needs to anticipate Memory (ability to recall three items) using therapeutic medications to help in stabilize Judgment (process of forming an opinion that the patient with TBI. is accurate and reasonable) The nursing objective in caring for the patient Cognition (serial 7s) with TBI is vigilant, accurate, and objective monitoring. This objective is achieved with a Motor Testing strong knowledge base of anatomy, physiology, Flex and extend all extremity joints against and keen observational skills. resistance Grading: Regardless of the skill level, a standardized tool or 5/5: Movement against gravity with full instrument needs to be used properly to quantify resistance the patient's assessments and to make 4/5: Movement against gravity with some comparative assessments. resistance 3/5: Movement against gravity only The most prominent and widely used tool for 2/5: Movement with gravity eliminated tracking a patient's neurologic baseline and injury 1/5: Visible and palpable muscle contraction; progression is the GCS. The GCS uses a number no movement system to describe level of consciousness (LOC). 0/5: No contraction The GCS ranges from 3 (poor, no response) to 15 (normal). The GCS rates (1) eye opening, (2) motor movement of the arms and legs, and (3) verbal response. Adding the scores from the three parts of the scale produces an overall score. Importantly, the GCS does not determine or predict the patient's final outcome. A drop of more than 2 points in the total gcs score is a sign of dangerous neurologic deterioration. A complete neurologic examination requires assessment of the pupils and extremities. These assessment components are completed in the mental status, motor movement, and cranial nerve assessments along with pupil responses. Neurologic changes and trends are best observed by conducting serial assessments, using a standardized format, and ensuring that all elements are approached in the similar manner. These standardized serial assessments ensure that each examiner encounters less variation and can thus provide a more objective clinical record. 14  medications are available for use in the treatment of TBI; when these agents fail or require augmentation, invasive procedures are then used to relieve pressure on the brain. Corticosteroid therapy-current research indicates that the use of steroids is not beneficial in the treatment of ICP. In addition, they suppress immune response, placing the patient at increased risk for infection. The drug is not contraindicated and may still be used in some hospital settings. → Olfactory-assessment of ability to smell PHARMACOLOGIC TREATMENTS → Optic-assessme (PERRLA) of vision; document Modality 1: pupils equal, round, reactive to light and Sedation Benzodiazepines accommodation Midazolam (Versed)-used most often to → Oculomotor-assessment of eye movement and prevent agitation Adults: Titrate slowly to tracking achieve desired effect. Usual dose range is → Trochlear-assessment of eye movement between 1 and 5 mg IV administered over a 2- → Trigeminal-assessment of bilateral facial minute period. sensation and ability to chew Opiates → Abducens assessment of lateral eye movement Morphine sulfate used to treat pain Adults: 4 → Facial-assessment of whether smile is to 10 mg IV; with appropriate dose titration, symmetric there is no maximum dose of morphine. → Auditory-assessment of hearing and balance Modality 2: → Glossopharyngeal assessment of gag reflex Fluid Reduction Osmotic diuretics and ability to feel ears Mannitol (Osmitrol)-predominate drug used in → Vagus-observe the soft palate and check to see the United States* Adults: Initially, 1.0 to 2.0 whether arch is symmetric (the "aahh" test) g/kg IV, followed by 0.25 to 1.00 g/kg IV q4h * → Accessory-assessment of shoulder muscle The mechanism of action mannitol (Osmitrol) resistance as patient shrugs shoulders remains unclear; however, it reduces ICP, → Hypoglossal assessment of tongue position draws water off the brain, can affect cardiac preload, and, in turn, increases CBF. Pupil changes will be on the same side (ipsilateral) as the brain injury; extremity symptoms At this point in the patient's treatment, (weakness) will be in the opposite side assessment and reassessment continues with a (contralateral). goal of obtaining radiologic studies (e.g., computed The recurring theme in managing the patient tomography [CT], x-ray series, and possibly a with TBI is the importance of monitoring and magnetic resonance image [MRI], depending on managing the ICP. availability and condition of the patient). The immediate treatment goal in the acute phase of brain injury is to keep the patient's Baseline blood work is prescribed with close environment quiet to avoid agitating the attention to arterial blood gas (ABG) results, patient further and inadvertently increasing hemoglobin, hematocrit, and other values based the ICP. on the complete patient history. The extent of the Equally important in reducing elevated ICP patient's TBI and resultant deficits is determined are medications designed to manage and during the first hours or days after the initial care reduce the fluid (blood or obstructed CSF) and is received. edema collecting on the brain. Only a few 15 ACUTE HEMORRHAGE RELATED TO GUNSHOT WOUND ✓ Contamination of the wound may result from → Penetrating trauma is one of the leading the debris and bacteria that has been pulled causes of hemorrhage, and gunshot wounds into the wound. are the leading source of high-velocity ✓ The bullet easily lodges in or travels through penetrating trauma. organs with the end result being organ or hemodynamic compromise (or both), A These injuries are often treatment dysfunction, or even death. challenges, particularly because only a small hole may be observed externally; however, Tissues that are elastic sustain less damage. internal injuries may be massive and life The bullet and its path is nondiscriminatory threatening. and destroys or damages muscle, vascular Once a bullet penetrates the skin, it meets tissue, nerves, and bone tissue. resistance as it travels at a high velocity Different tissues have varying degrees of through the tissues, creating an enlarged, specific gravity or density that determine how cone-shaped path that results in significant much energy can be transferred from the damage to tissues. bullet to the tissues. Tissue that is dense has The bullet either exits or comes to rest within a tendency to take up more energy, resulting the body. According to the American Trauma in greater damage. Life Support (ATLS) Manual, the important For example, ribs have a specific gravity of indicators for determining the extent of 1.11 and lungs have a specific gravity of only injuries include the gun caliber, the presumed 0.5 to 0.4. As expected, if a bullet strikes a rib, path and velocity of the bullet, and the the rib shatters, creating more projectiles and distance from the weapon to the victim's the possibility of significant damage to entrance point. surrounding structures and tissues. Suicides are usually single shot intraoral However, if a bullet strikes a lung, damage to wounds whereas homicides are multiple shots the lung may cause tremendous detriment to to the temporoparietal region. the patient secondary to oxygenation issues, but damage to the surrounding tissues is not Kinetic energy, which is carried by the bullet and directly affected by the damage to lung tissue. subsequently transferred into the tissues, causes the damage in a gunshot victim. Handguns shoot a single bullet that contains powder encased in metal, whereas shotgun Many sources describe the entrance wound shells are metal encasements containing (inlet velocity) (V1) as the maximal point of multiple smaller pellets-as few as six or as energy. If the bullet never exits the body, the many as 200, depending on the gauge of the exit wound (outlet velocity) (V2) is said to be shotgun. Broadly, what happens when a gun is zero. fired is that a dart-shaped projectile (bullet) is One bullet can cause tremendous damage by launched at significant speed through the bore deflecting off bone and traveling across the of a gun. body, damaging many structures in its path. The bullet may deviate slightly from its path As the projectile of the bullet travels, it meets and begin to slow, secondary to the air force resistance of the tissues, which is known as encountered once it leaves the gun and enters retardation. the atmosphere. The speed at which the bullet The high V1 creates an inward path along meets the skin is V1, where most of the energy which the bullet travels, but a negative is expended into the tissues. It may penetrate pressure also exists behind the bullet, which as a direct hit or on an angle, which affects pulls debris and bacteria into the wound. how the bullet will travel as it progresses 16  through the layers of tissue. Some bullets may indicate that he or she is hemorrhaging travel in a slightly upward and downward internally. motion as they push forward; this is known as Patients with class I and II blood loss can be yawing. managed with crystalloid replacement at a Other bullets tumble end-over-end through rate of 3 mL for every 1 mL of blood loss. the tissues. Either way, the extent of damage Patients with class III and IV blood lost, is directly related to the transference of energy however, require blood replacement therapy in from the bullet into the tissues. Some addition to crystalloids. manufacturers manipulate bullets to create Patients with class IV hemorrhage usually die more devastation on impact; the hollow- point if immediate emergency intervention is not bullet is an example. implemented because compensatory mechanisms are short term and inadequate to Hollow-point bullets tend to flatten and implode handle a blood loss of this volume. on impact and transfer a great amount of KE. In contrast, smaller-diameter or lower-caliber The main treatment goals are to decrease blood bullets tend to produce less damage. loss and increase intravascular volume. These goals can be accomplished by instituting V2 is the velocity at which the bullet exits the specific interventions to control bleeding and body. As previously mentioned, if the bullet fails to replenish intravascular volume with to exit the body, V2 is equal to zero. The crystalloids and/or blood products. If the calculation describing this concept is the "law of patient continues to bleed despite energy" output. resuscitative measures, surgical intervention may be necessary. The patient who is hemorrhaging-internally or externally- exhibits the pathophysiologic signs and symptoms of hypovolemic shock. An increased V1 and decreased V2 result in significant internal damage. Some degree of FIRST LINE AND INITIAL TREATMENTS FOR hemorrhage is frequently involved with the ACUTE HEMORRHAGING victim of a gunshot wound. Hemorrhage refers Secure or support a patent airway (cervical to a rapid loss of circulating intravascular spine precautions). volume. Optimize breathing. Maintain circulation. Various stages of hemorrhage are Establish intravascular access with large bore characterized by the amount of blood lost, in catheters. relation to the total blood volume. Replace intravascular volume (blood products Unfortunately, no one at the scene can collect or crystalloids). the blood that has been lost and then inform Manage bleeding by applying direct pressure the emergency department personnel of the on a compressible site. need for fluid resuscitation and/or blood The usual ABCs should be followed in the transfusion. management of the patient with hemorrhage. Another concern is that the patient's bleeding The airway should be assessed, oxygen should may be primarily internal. Even when a be applied, and, if necessary, the patient significant amount of blood has not been should be intubated. The goal is to maintain identified at the scene, the patient can exhibit tissue perfusion. The patient has already lost symptoms of intravascular depletion, which some oxygen carrying capacity secondary to 17  the bleeding; therefore, it is important to mL of blood loss. All fluids should be warmed, saturate the hemoglobin that remains with as and a rapid infusing device may be necessary. much oxygen as possible to enhance tissue The American College of Surgeons perfusion. recommends fluid replacement with 1 to 2 L of Vasopressors, steroids, and sodium bicarbonate fluid administered rapidly for the adult SHOULD NOT be considered in the initial patient and 20 mL/kg for the pediatric patient. treatment of the bleeding patient. Patients must It is reasonable to have lactated Ringer's have their intravascular volume replenished first. solution infusing on one body side and NS Cervical spine precautions are included in the infusing on the other body side in preparation A of the ABCs of all trauma patients. Without for possible blood transfusion. proper stabilization, securing a patent airway Blood transfusions should be considered when may not be possible without compromising the the intravascular requirements are not being integrity of the cervical spine. met by crystalloid infusion. Initially, O- Careful assessment of breathing and assisting negative packed red blood cells (PRBCs) may or managing ventilation as necessary are be given; however, once the type and cross required. Circulation should be assessed by have been completed, patient-specific blood both physical examination and vital signs. should be transfused. Estimating the patient's SBP is accomplished Whole blood is rarely administered, although by palpating the pulses and assessing the it would provide all the blood components that pulse characteristics (i.e., rate, rhythm, the patient has lost and decrease the exposure strength). to the number of donors. Pulse Site Approximate SBP Value Radial 80 Whole blood is not usually given because most mm Hg Femoral 70 mm Hg Carotid 60 mm Hg. patients do not need all the components. A urinary catheter should also be placed to assess Further, most blood banks cannot store whole the patient's fluid status and the adequacy of blood cost effectively. renal perfusion. O-negative blood is usually transfused in the At this time, two IV accesses should be emergent patient without a type and cross obtained with large-bore (16- or 18- gauge) IV match. O-positive blood may be substituted in catheters, preferably in the upper extremities; life-threatening situations if O-negative blood antecubital is preferred. is not available. The prudent practitioner should also collect When the patient's blood volume has become blood to be sent for baseline testing that significantly depleted, additional transfusions includes complete blood count, basic metabolic with other blood components may be panel, prothrombin time, partial indicated. Devices may be used to assist in thromboplastin time with international attaining hemostasis from an actively normalized ratio (INR), type and cross match, bleeding wound in addition to increasing ABGs, and beta human chorionic venous return. gonadotropin (hCG) in women of childbearing Tourniquets are no longer indicated in the age to determine whether the patient is treatment of hemorrhage because they cause pregnant. ischemia to tissue distal to the injury. The only Fluid resuscitation should be initiated with time the application of tourniquets is used is crystalloid solutions, normal saline (NS), or in the event of traumatic amputation. lactated Ringer's solution. Prevention of hypothermia in the FIRST LINE AND INITIAL TREATMENT FOR hemorrhaging patient is another very BLOOD LOSS important intervention. Although it is Infuse Lactated Ringer's solution. Crystalloids important to expose the patient to assess for are administered at a rate of 3 mL for every 1 injuries, maintenance of body temperature is critical, and all fluids and blood should be 18  warmed either before or during administration. Patients with hypothermia who are bleeding have less ability to tolerate the loss in blood volume. The result of massive blood loss is hypovolemic shock. Rapid and aggressive intervention is critical in the hemorrhaging patient to prevent the deterioration and possible hemodynamic instability of the patient. The nurses' role in the management of the Many diseases may result in cardiac patient who is hemorrhaging from a gunshot tamponade. These include acute and chronic wound is of utmost importance, and the pericarditis, cancer, renal disease, HIV-TB co- information gathered or missed can infected patients, and systemic lupus significantly influence patient outcomes. erythematosus. Cardiac tamponade may also occur as the CARDIAC TAMPONADE result of certain procedures: for example, Cardiac tamponade is a life-threatening cardiac catheterization, balloon angioplasty, condition where no blood is ejected from the pacemaker insertion, central line insertion, heart, resulting in cardiac arrest. transmyocardial revascularization, fine- It requires immediate intervention. needle biopsy of the chest, coronary artery Cardiac tamponade is defined as major bypass surgery, and heart transplantation. compression of all four chambers of the heart Certain medications also predispose patients caused by an accumulation of one or more of to tamponade. These medications include the following: blood, clots, pus, other fluid, or anticoagulants, chemotherapeutic agents (i.e., gas. abciximab), and thrombolytic agents. Acute The fluid accumulates in the pericardial sac cardiac tamponade may also occur as the that surrounds the heart, almost completely result of chest trauma or rupture of the heart obstructing venous return, causing after a myocardial infarction (MI). hypotension and jugular venous distention. SIGNS AND SYMPTOMS The amount of fluid necessary to cause cardiac The patient may report chest tightness, tamponade in an adult varies. As little as 150 dizziness, shortness of breath, vague mL of rapidly accumulating fluid to 1 L of discomfort, dysphagia, and dysphoria slowly accumulating fluid in the pericardial including restlessness and statements of sac can cause cardiac tamponade. impending death. This fluid accumulation increases the pressure Clinical signs include tachycardia, edema, a in the pericardial sac. positive hepatojugular reflex, reduced This rising pressure results in an equalization extremity pulses, rising central venous of the diastolic pressure in all four chambers pressure, a decrease in the difference between of the heart. This change in pressure leads to the SBP and diastolic blood pressure (DBP) a decrease in cardiac filling, resulting in a (narrowing of the pulse pressure), shocklike decrease in stroke volume. symptoms, and pulsus paradoxus. Cardiac tamponade becomes fatal when the Pulsus paradoxus is defined as a greater than pericardial pressure increases to the point 10-mm Hg drop in SBP occurring on that the heart cannot effectively pump to inspiration. The condition indicates high maintain circulation. thoracic pressure. Pulsus paradoxus can be observed on arterial line tracing or measured using a sphygmomanometer. It is more 19  pronounced in patients with lung masses or in those profusely dehydrated. An electrocardiographic (ECG) tracing may show a decrease in the amplitude of the QRS complex, an alternating high and low voltage where the R wave alternates between upward and downward deflections (electrical alternans), and other T- wave abnormalities. However, ECG changes are observed in only about 20% of patients with tamponade. Once the diagnosis of tamponade has been confirmed, a physician needs to remove the excess fluid in the pericardial space by needle aspiration, needle pericardiocentesis, or open surgical drainage. Needle pericardiocentesis alternating high-low voltage. V3 = decreased can be performed at the bedside using a local amplitude in QRS complex. V6 = t-wave anesthetic; it involves the insertion of a needle abnormalities. through the chest wall into the pericardial sac. HEART CATHETERIZATION AND The fluid is gently aspirated. The ECHOCARDIOGRAPHY characteristics of the fluid aspirated will vary Can confirm cardiac tamponade with the cause of the tamponade. For example, An echocardiogram is the safest method for the fluid appears bloody if the tamponade is detecting cardiac tamponade and is used more the result of bleeding, but it may appear frequently because of the time required to purulent if the cause is infection. A sample of prepare the client for a heart catheterization. the fluid should be sent to the laboratory for An echocardiogram shows increasing tricuspid smear, culture, and cytologic studies. and pulmonary flow velocities and decreasing THE REMOVAL OF AS LITTLE AS 10 ML OF mitral and aortic valve flow velocities during PERICARDIAL FLUID CAN MEAN THE inspiration. DIFFERENCE BETWEEN LIFE AND DEATH A heart catheterization shows that the right FOR THE PATIENT. atrial, pulmonary capillary wedge, and The goal of most nursing interventions is early pulmonary artery DBPs are elevated and are detection of cardiac tamponade. all equal (within 5 mm Hg). Cardiac output is Any patient undergoing a procedure that also decreased, whereas systemic vascular places him or her at high risk for cardiac resistance is elevated. tamponade should be closely monitored for at A chest x-ray shows an enlarged heart, which least 24 hours after the procedure. can indicate tamponade when compared with The patient is observed for symptoms previous x-ray studies. associated with cardiac tamponade (e.g., shortness of breath, vague discomfort, anxiety, dizziness, JVD, chest tightness or discomfort). Heart tones and breath sounds are assessed, paying particular attention for muffled heart tones (possibly indicative of cardiac tamponade) or adventitious breath sounds (possibly indicative of other problems). Vital signs are monitored for tachycardia (adults) or bradycardia (infants), for changes 20  in BP, and for narrowing of pulse pressures Request an immediate chest x-ray study, 12- and pulsus alternans. lead ECG, and echocardiogram.\ Obtain IV access. Prepare for pericardiocentesis (needle or subxiphoid). During pericardiocentesis, the ECG should be monitored for arrhythmias; vital signs should be monitored during the procedure. After the procedure the vital signs are monitored every 15 minutes for the first hour and then agency policy should be followed for frequency of vital signs. After the procedure, the dressing over the needle insertion site should be monitored. NURSING INTERVENTIONS Any excessive drainage (>200 mL/day) should If the patient has a pulmonary artery catheter be reported to the physician. Drainage is in place, central venous pressure, pulmonary usually serous or serosanguineous. capillary wedge pressure, and cardiac output are monitored. OVERDOSE An ECG is assessed for changes in voltage and Intentional drug overdoses are the most alternating patterns of high and low voltage. common reported method for attempted Laboratory values are monitored for signs of suicide. Treatment includes stabilization, dehydration and hypokalemia. Hypokalemia reducing further drug absorption, eliminating can precipitate arrhythmias during the drugs from the body, and ongoing pericardiocentesis. monitoring. Intake and output levels are monitored to Any drug or medication has the potential to assess for dehydration. cause an overdose. Both legal and illegal drugs Chest tube drainage of a patient who has had can be lethal when improperly used. The open-heart surgery is closely monitored patient with a possible drug overdose requires because blocked or kinked chest tubes can emergent care and can be a challenge for the result in cardiac tamponade. A sudden health care provider. decrease in chest tube drainage should be A drug overdose can result in multisystem investigated. involvement that dictates the need for When cardiac tamponade is suggested, oxygen immediate attention to avoid further is administered. complications. The physician is immediately notified, and an The nurse should also determine whether the immediate request for a chest x-ray, 12-lead overdose was accidental or an attempt to ECG, and echocardiogram is prescribed. commit suicide. If the patient does not already have an IV in Until this issue is resolved, patients must be place, one should be started. closely monitored to ensure no further If time allows, a blood sample is sent to the attempts at self-harm are made. laboratory for type and cross match and for an Stabilizing the patient's physical condition is assessment of the potassium level. the first and most crucial treatment step. Hypokalemia can increase the occurrence of The older adult is at greater risk for arrhythmias during pericardiocentesis. inadvertently overdosing or underdosing FIRST LINE AND INITIAL TREATMENT FOR medications because of diminished eyesight. CARDIAC TAMPONADE The initial evaluation of a patient with a Provide oxygen. possible drug overdose includes Notify physician. 21  obtaining a complete and reliable history. The Each assessment finding will help identify the goal is to identify the drug or actual and possible systems affected by the drugs taken alone or in combination with drug overdose and will also provide clues as to other drugs or substances. the type of drug or drugs used and how each It is important to find out what drug has been was introduced into the system. taken, what amount has been taken, and the For example, the inspection of the skin may time of the intake. Any medical and reveal fresh needle marks. psychiatric history, current medications, The ideal first step is to obtain a complete allergies, and any history of drug overdose history and physical evaluation; however, a should also be obtained. critical patient requires immediate medical Next, a thorough physical examination is interventions. performed, which provides baseline Assessment of the LOC is necessary to information and identifies any physical determine whether the patient is alert, symptoms. This examination must be arousable, or unresponsive. Sufficient completed as quickly as possible because time ventilation and perfusion must be priorities. is of the essence. The initial physical Airway and breathing assessment is evaluation must determine whether the performed to ascertain whether the patient's patient's life is in immediate danger and trachea is blocked. identify any additional medical conditions or Correct positioning of the head (head tilt-chin injuries that might become a concern while lift or jaw thrust) prevents the posterior of the providing the necessary care for the overdose. tongue from occluding the airway. This Obtaining a complete history may be difficult positioning may be all that is required to because the patient may be in a state of ensure that the patient can resume breathing confusion, unconscious, or unable to provide on his or her own. Intubation may be information. In such cases, family members necessary in the patient who is comatose, has may be the main source of information. lost the gag reflex, or is having seizures. In other cases, the patient and family may find Oropharyngeal airways can also assist. These it embarrassing to provide information related airways are used in the patient who is to the addiction, or the patient may be found spontaneously breathing but remains alone, or he or she has been brought to the unconscious. These prevent the tongue from hospital for emergent care. In these cases, the blocking the airway and provide for suction of emergency medical technicians may become secretions. If possible, oxygen should be the main source of information. administered after ABGs are obtained. Those providing patient information should be FIRST LINE AND INITIAL TREATMENT FOR questioned about the circumstances in which THE PATIENT WHO HAS OVERDOSED the patient was found by asking the following 1. Assess responsiveness. questions: 2. Establish an airway (head tilt-chin lift position, ✓ Was the patient conscious? jaw thrust, oropharyngeal airway, intubation). ✓ Could he or she provide any 3. Provide oxygen. information when initially found, 4. Check pulse. If no pulse, initiate CPR. including location and time? 5. Initiate cardiac monitoring. ✓ Were any prescription bottles present- 6. Establish IV access (20- or 18-gauge for an with or without pills? adult). ✓ Was any drug paraphernalia found? 7. Provide fluid replacement. The initial physical evaluation should include 8. Determine substances taken; give appropriate the review of vital signs, skin, breath (odor), reversal agent. ears, nose, throat, lungs, heart, abdomen, IV lines need to be initiated as soon as extremities, and neurologic (seizures) status. possible. Fluid replacement is necessary for 22  patients who experience drug-induced We no longer induce emesis in patients, so the hypotension. In addition, the IV route is use of ipecac syrup is no longer done. preferable for administering medications. Gastric lavage is another method for removing For the patient with cardiac compromise, a gastric contents. This procedure calls for the central venous line may also be indicated and passage of the largest tube passable through an ECG may be prescribed to assist in the patient's oropharynx. A 32- to 40-French determining the presence of any cardiac orogastric tube is used in an adult. injury. The patient's cardiac status needs to be The patient is placed in a left lateral decubitus monitored until medically cleared. Trendelenburg position with knees flexed. If the patient exhibits an altered mental This position allows for the greatest status, a trial dose of a therapeutic reversal abdominal relaxation and gastric emptying, agent may be administered. Naloxone and it reduces the risk for aspiration in case (Narcan), dextrose, thiamine, and oxygen are emesis occurs. all considered safe and innocuous agents. Confirmation of proper tube placement is Glucose and thiamine may be life-saving obtained before lavage and via an x-ray film. measures to the patient who has Tap water or saline, typically 10 to 20 L, is hypoglycemia. Thiamine is also effective in induced into the stomach. The solution may be preventing Wernicke-Korsakoff syndrome, warmed, which hastens the dissolution of pills which is associated with alcohol withdrawal. that remain in the stomach. Focus Areas for the Management of the Patient The solution is then emptied from the stomach Experiencing an Overdose by way of lowering the tube to the floor and Supportive care siphoning off the fluid or suctioning, which is Prevention of absorption known as stomach pumping. The patient is Enhancement of excretion (if possible) lavaged until the return is clear. Administration of an antidote (if available) One of the more important elements in the management of the patient who has ingested an overdose is supportive care. This includes frequent monitoring of vital signs with particular focus on the temperature, which helps identify hypothermia or hyperthermia. It is necessary to monitor multiple systems as indicated to identify any system failure. An oral slurry of 60-100 grams for adults and 15-30 grams for children of a mixture of activated charcoal and sorbitol is used in conscious patients with a gag reflex. This can be given in multiple doses as needed. Most overdoses occur by way of the gastrointestinal tract. In these situations, it is most important To decrease drug absorption, activated that further gastrointestinal absorption be charcoal and a cathartic are administered. stopped. Several methods are available to Absorbents provide the means for decreasing remove the drug from the gastrointestinal any further absorption of the involved tract. These include emesis, gastric lavage, overdose drug into the system. cathartics, and absorbents. Activated charcoal plays a major role in the Gastric lavage is no longer considered effective treatment of the overdose patient. Activated when the patient has taken medications in the charcoal is a residue of destructive distillation last 45 minutes. of burned organic materials such as wood, 23  pulp, paper, bone, and sawdust- to name a few. In addition, caution must be taken regarding Heating with CO2, which increases the possible fluid and electrolyte shifts that occur surface binding area and in turn increases the when an enema is administered. absorption ability of the materials, activates Forced diuresis involves the flow of urine at the charcoal. the rate of 3 to 5 mL/kg/hr, which may require Activated charcoal is a fine, black powder, a diuretic. This process should only be used tasteless and odorless, with a gritty when specifically indicated, such as an consistency. It is mixed with 60 to 90 mL of overdose with phenobarbital, bromides, water to make a slurry. Between 30 and 100 g lithium, salicylate, and amphetamines. for an adult is then induced into the stomach It is not used frequently because of by way of an NG or lavage tube. It can be complications such as volume overload or administered orally if the patient is alert and electrolyte disturbances. cooperative. The recommended dose for an Weak acids are ionized in a more alkaline adult is 50 to 100 mg mixed in 8 ounces of medium, and weak bases are ionized in a more water. acidic medium. If a pH difference exists across Sorbitol 33 cc and activated charcoal 50-75 the membrane, ion trapping occurs. More total grams via gastric tube is a common treatment drug exists in the compartment where for overdose in adults. ionization is greater because the non-ionized Cathartics are administered as a means of form crosses the lipid cellar membrane more eliminating drugs from the gastrointestinal readily than does the ionized form. tract, as well as assisting with the passage of Hemodialysis and hemoperfusion can be charcoal. They decrease the gastrointestinal valuable adjuncts to treatment, although transit time of the drug, thus decreasing the many drugs such as diazepam (Valium), possibility for absorption. The cathartics digoxin (Lanoxin), and phenytoin (Dilantin) include the following agents: sorbitol, are not well removed with these invasive and magnesium sulfate (Epsom salt), magnesium complicated procedures. citrate, sodium sulfate (Glauber's solution), Some patients who come to the emergency and disodium phosphate (Fleet enema). department with an overdose may respond to The fastest and most potent cathartic is the the administration of an antidote. osmotic agent sorbitol. Magnesium sulfate and Antidotes are divided into physiologic and magnesium citrate and hypertonic saline specific. General or supportive antidotes are agents are slower acting, and magnesium also available. General or supportive levels need to be monitored. antidotes, which include activated charcoal Multiple methods can be used to enhance the and sodium bicarbonate, are not true antidotes excretion of drugs from the body. These but help treat overdose symptoms. include forced diuresis, alteration of urine pH, hemodialysis, and hemoperfusion. Each has limited use and is instituted when an antidote is not available. Disodium phosphate (Fleet enema) must be used cautiously in children because of anatomic and physiologic factors. Absorption of the drug depends on the anatomic care of the rectum. Medications administered in the lower portion of the rectum bypass the liver circulation and metabolism. 24