3-27-08 Mrs.

Batton

Emergency Care
Emergency Management

• Care given to clients with urgent and critical needs

• An emergency is whatever the client or their family considers it to be

• This type treatment is provided under the direction of a physician or

Emergency Nurse Practitioner

Delivery of Emergency Care

• Hospital emergency department

• Diagnosis, treatment, and stabilization of life threatening emergent

conditions

• Symptomatic care and referral of non-urgent conditions

• Community Emergency Care- 911 EMS system in MS

Protection of Legal Rights

• Proper reporting to authorities

o GSW’s

o Intentional injuries

o Child and Elderly abuse

o Certain diseases

o Deaths

• Trauma has potential legal implications

• Preservation of Evidence

o Rape kit

o Weapons

o Clothing

o Specimens

ED Classifications
 • Level 1 Trauma Center

o UMC

o 24-7 OR’s that are completely staffed

o Physicians and nurses on call for OR and ED 24-7

o Must have the ability to have transports in 24-7

• Level 2

o 24 hour coverage by physician and RN

o Specialty services can get there within 30 minutes

• Level 3

o 24 hour coverage by RN

• Level 4

o All they can do is first aid care and enemas

ED layout

• Triage area-to sort out clients

• Trauma Room-larger room assessable to multiple machines and people

• Orthopedic room

• Suture room

• Observation area

• Clinic area

• ENT room

• Psych Holding

• X ray

• Close proximity to OR

• Waiting Room

Triage
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• Means “to sort”

• Advanced skill

• Should occur 2-5 minutes from patients arrival to the ED

• A systematic approach to assessment that allows the ED nurse to determine

what clients need immediate treatment and those who can safely wait

• Places clients in groups based on severity of problems and immediacy of

needed treatment

• Differs between ED and in the “field” (disasters).

Nurses Role in Routine ED Triage

• Collect data

• Assess vital signs

• Neurological assessments if indicated

• In the hospital triage directs all available resources to clients who are the
most ill

ED Triage Categories

• Emergent- highest priority

o Life threatening (symptomatic neonates)

o Pregnant woman that has something life threatening to her or her baby

• Urgent- serious sick but not about to die (can wait up to an hour in the
waiting room)

• Non-urgent- less serious not going to die anytime soon, could probably be
seen at clinic

• Fast-Track-first aide or basic care

Nursing Assessment in Emergencies

• Primary Survey

o A-airway
 o B-breathing

o C-circulation

o D-disability/ Neurological

o E-exposure

Airway/ Breathing Maintenance

• Oropharyngeal

• Endotracheal Intubation

• Cricothyroidotomy

Circulation

• Always take care of airway/breathing first

• Usually due to hemorrhage or shock

• If external hemorrhaging-open airway and then control bleed, especially if

arterial

• Apply pressure and elevate extremity for bleed

• Initiation of IV’s to restore volume

• Tourniquet is always last resort unless traumatic amputation has occurred

• Draw blood for cross match

• Two large bore IV’s if actively bleeding

• Anytime you’re giving lots of blood use blood warmer- start watching calcium
levels-hypocalcemia

Disability/Neurological Assessment

• Assess mental status

• Glasgow coma status

• AVUP

o Alert

o V -responsive to voice
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o U-Responsive to pain

o P-Unresponsive

• Assess anxiety level

Exposure

• Final component of primary survey-Check for exit wounds

• Remove all clothing to allow for thorough assessment

• Be aware of potential need for evidence collection

Pain

• Client’s complaining of severe pain should be moved up in priority

• Sever pain is defined as client’s self rating of 8-10 on a scale of 0-10

Secondary Survey

• Complete health history

• Head to toe assessment

• Diagnostic and labs

• Monitoring (EKG, Foley, Arterial Lines)

• Splinting fractures

• Clean/ dress wounds

• Any other interventions based on client needs

Abdominal Trauma

• Goal-control bleeding and maintain blood volume

• GSW-what kind and how far away they were when they got shot

• Assess-what happened, when, how, How many times, did they stay conscious

• Auscultate-bowel sounds

• Palpate-rigidity, guarding, tenderness, measure abdominal girth

• Insert foley
 • Labs- H and H

• Urinalysis for hematuria

• Left shoulder pain can equal ruptured spleen

• Cut away clothes

• Control bleeding

• Start IV (be prepared to treat shock)

• Cover with sterile dressing

• Ng tube

• Continuous vital signs

• Neuro status

• X-rays

• Labs

• Medicine

• Peritoneal lavage

• Prepare for OR

Crushing Injuries

• Assess

o Hypovolemia

o Paralysis

o Skin

o Renal

o Serum lactate want it less than 2.5

• May require fasciotomy

• Hyperbaric chamber sometimes used during recovery

Near Drowning Emergency Management

3-27-08 Mrs. Batton

• Problem is hypoxia and acidosis

• ABC’s

• Arterial blood gases

• 100% O2 PEEP to improve gas exchange

• Cardiac monitoring

• IV

o Salt water=LR

o Fresh water = INT

• Labs

• Meds

• NG tube and foley

• X-ray

• Monitor vital signs

Decompression sickness

• Signs and symptoms

o Joint, extremity pain

o Numbness

o Loss of ROM

o Neurological symptoms may mimic a stroke or spinal cord injury

• Airway

• Ventilate

• 100% O2

• IV with LR or NS

• Chest X-ray

• If embolus suspected lower head of bed

 • Keep warm

• Hyperbaric chamber ASAP

• Antibiotics if aspiration

Poisoning Emergency Management

• Ingested (plants, drugs, foods, chemicals)

o ABC’s (v/s, o2, ABG’s, EKG)

o Call poison control

o May be corrosive (determine type of product ingested)

o Position on left side

o Monitor neurological status

o NGT for gastric lavage

o Give milk or water to dilute

o Do not make vomit if caustic

o If caustic assess for mouth, esophagus burns

o Activated charcoal (PO-NGT)

o Cathartic (mg. citrate)

o Syrup of Ipecae (only if alert and able to swallow and no longer

recommended)

• Ingested Poisoning

o ABC’s vital signs, EKG, muscular activity

o Place on side

o IV

o Treat signs and symptoms, nausea and vomiting

o Determine source and type of food or ingestant

o Reporting may be necessary

• Inhaled poisoning
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o Carbon monoxide, gas, smoke, fumes

 Carbon monoxide most common

 Carboxyhemoglobin levels

 100% o2

 Monitor for deterioration of mental status

 Notify Psych if attempted suicide and health department if

indwelling

 May cause permanent brain damage

• Skin Contamination

o Remove clothes

o Profuse amounts of water to flush all traces of chemical away from

body (unless chemical was Lye or white phosphorus)

o Manage as burn after removal of agent

• Injected

o Bugs

o Snakes

 Pit vipers

 Coral snakes

 Inject poison through fangs-but fang marks don’t always equal

venom

 Signs and symptoms

• Pain at site

• Petechiae

• Metallic taste in mouth

 Immobilize

 Keep bitten body part below the level of the heart

  Don’t apply tourniquet

 Don’t apply ice

 Don’t apply tourniquet

 Give tetanus shot

 Give anti venom, be sure they are not allergic

• Pre medicate with Benadryl or H2 blocker

• Diluted will 500cc saline, given over 4-6 hours can be

repeated

 May I&D the area

 May need fasciotomy for edema

 No corticosteroids between 6-8 hours after bite

o Spiders

 Brown recluse bites

• Cytotoxic venum-kills the cells

• Might not have symptoms at first, then gets painful later

on

o Develops dark, hard, area after a few days

o Bullseye necrosis causes hole

• Will probably I&D it

• May give corticosteroids and antibiotics, anti-histamines

• Patient may need skin grafts

 Black Widow Spider Bite

• Neuro toxic venum-causes neurological deficits

• Patient has pain when they are bitten

o See edema in area

o Start cramping and vomiting

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o Stomach may be rigid and tender

• May give muscle relaxants

• May need anti-venom

o Do skin test or eye test before you give it

o Will prevent long term complications

o Will give in piggy back

o Give over at least 2 hours

o May be repeated

• Heat Injuries

o Heat exhaustion-moist and clammy, pupils dilated, normal or

subnormal temp

 Cool as rapidly as possible

 Allow to rest

 May give sodium and water (Gatorade)

 Keep them still

o Heat stroke- dry, hot skin

 Life threatening

 Happens in hot, humid, environment get hotter and hotter and

hotter

 Decrease core temperature

 Body has given up, no longer perspiring

 Patient may be dizzy or confused

 Put ice packs on groin, neck

 IV fluids to cool them

 ABC’s

 Foley
  EKG monitoring

o Heat cramps

 Painful spasms due to sodium depletion

 Seen a lot in high school atheletes

• Cold injuries

o Hypothermia

 Temp less than 95 degrees

 Get confused, pulse and blood pressure start to drop

 Not dead until they are warm and dead

 Good chance of ventricular arrhythmias

 Warm core first

 Monitor closely on EKG

 ABG’s

 Foleys

 May give bicarbonate

o Frostbite

 Cold, painful, discolored extremities

 Pain gets worse as we warm them

 Warm with tepid water very slowly, give pain med first

 Elevate extremity

 Never allowed to smoke because of vasoconstriction

Sexual Assault

• Check protocol

• Consideration must be made for physical and emotional needs as well as

collection of forensic evidence
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• Assign SANE nurse to provide care

• Do not use the word RAPE

• Obtain witnessed, informed consent for examination, photographs, and

release of information/ findings to police

• Obtain history once-no repeats!

• Never use lubricant for vaginal exam

• If possibility of ghonnorea involved will have Rocephin prophylacticly

• May be put on syphilis prophylaxus

• May give morning after pill

Emergency Drugs

• O2

• Epinephrine

o Cardiac stimulate and bronchodilator

• Atropine

o Asystole, low heart rate

• Lidocane

o Ventricular arrhythmias

• Amniodorone

o Vtach, v fib

• Narcane

o Reverses toxicity

• D50W

o For hypoglycemia

• Bicarb

o For metabolic acidosis

• Magnesium
 o Hypomagnesimia

• Dopamine/ Dobutamine

o Increase BP

o Increase cardiac output

Documentation

• Document everything

o Assessment

o History

o Vital signs

o Allergies

o Medications

o Last meal eaten

o How they arrived

o Pertinent statements from client with quotations

After unsuccessful codes

• Family is notified

• Family is supported

o Provide privacy

o Spiritual guidance

• Body is prepared

• Donor agencies are notified

• Coroner contacted

• Staff debriefing

• j