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E Cart
Located in designated areas where medical
emergencies and resuscitation is needed
Purpose: to maximize the efficiency in
locating medications/supplies needed for
emergency situations.
Drawer 5: Contains respiratory supplies
such as oxygen tubing, a flow meter, a face
shield, and a bag-valve-mask device for
delivering artificial respirations
Drawer 4: Contains suction supplies &
gloves
Drawer 3: Contains intravenous fluids
Drawer 2: Contains equipment for
establishing IV access, tubes for laboratory
tests, and syringes to flush medication lines.
Drawer 1: Contains medications needed
during a code such as epinephrine, atropine,
lidocaine, CaCl2 and NaHCO3
The back of the cart usually houses the
cardiac board.
Assessment and Intervention in the ER
The Primary Survey: Focuses on stabilizing
life-threatening conditions; employs the ABCD
Method
The ABCD Method
Airway - Establish the airway
Breathing - Provide adequate ventilation
Circulation - Evaluate & restore cardiac
output by controlling hemorrhage,
preventing & treating shock, and
maintaining or restoring effective
circulation
Disability - Determine neurologic disability
by assessing neuro function using the
Glasgow Coma Scale
Eye
opening
response
Spontaneous
To voice
To pain
None
4
3
2
1
Verbal
response
Oriented
Confused
Inappropriate words
Incomprehensible sounds
None
5
4
3
2
1
Motor
response
Obeys command
Localizes pain
Withdraws
Flexion
Extension
None
6
5
4
3
2
1
Head-Tilt-Chin-Lift Maneuver
1. Place the patient on a firm, flat surface.
2. Open the airway by placing one hand on
the victims forehead, and apply firm
backward pressure with the palm to tilt
the head back.
3. Place the fingers of the other hand under
the bony part of the lower jaw near the
chin and lift up.
4. Bring the chin and teeth forward to
support the jaw.
Clinical Manifestations
1. Choking
2. Apprehensive appearance
3. Inspiratory & expiratory stridor
4. Labored breathing
5. Flaring of nostrils
6. Use of accessory muscles (suprasternal &
intercostal retractions)
7. anxiety, restlessness, confusion
8. Cyanosis & loss of consciousness develops as
hypoxia worsens.
Assessment and Diagnostics
Involves simply asking whether the patient is
choking & requires help
If unconscious, inspection of the oropharynx
may reveal the object.
X-rays, laryngoscopy, or bronchoscopy may
also be performed.
For elderly patients, sedatives & hypnotic
medications, diseases affecting motor
coordination, & mental dysfunction are risk
factors for asphyxiation of food.
Victims cannot speak, breath or cough.
If victim can breathe spontaneously, partial
obstruction should be suspected; the victim is
encouraged to cough it out.
Compiled Notes of Bernie C. Butac
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Jaw-Thrust Maneuver
1. Place the patient on a firm, flat surface.
2. Open the airway by placing one hand on
each side of the victims jaw, followed by
grasping and lifting the angles, thus
displacing the mandible forward.
Oropharyngeal Airway Insertion
A semicircular tube or tube-like plastic device
inserted over the back of the tongue into the
lower pharynx
Used in a patient who is breathing spontaneously
but unconscious.
ET Intubation: Indications
1. To establish an airway for patients who
cannot be adequately intubated with an
oropharyngeal airway.
2. To bypass an upper airway obstruction
3. To prevent aspiration
4. To permit connection of the patient to a
resuscitation bag or mech. ventilator
5. To facilitate removal of tracheobronchial
secretions
Cricothyroidotomy
Used in the following emergencies in w/c ET
intubation is contraindicated:
1. Extensive maxillofacial trauma
2. Cervical spine injuries
3. Laryngospasm
4. Laryngeal edema
5. Hemorrhage into neck tissue
6. Laryngeal obstruction
Nursing Diagnoses For Airway Obstruction
1. Ineffective airway clearance due to
obstruction of the tongue, object, or fluids
(blood, saliva)
2. Ineffective breathing pattern due to
obstruction or injury
Hemorrhage
Assessment
Results in reduction of circulating blood
vol., w/c is the principal cause of shock
Signs and symptoms of shock:
1. Cool, moist skin
2. Hypotension
3. Tachycardia
4. Delayed capillary refill
5. Oliguria
Management
Fluid Replacement
Two large-bore intravenous cannulae are
inserted to provide a means for fluid and
blood replacement, and blood samples are
obtained for analysis, typing, & crossmatching.
Replacement fluids may include isotonic
solutions (LRS, NSS), colloid, and blood
component therapy.
Packed RBCs are infused when there is
massive hemorrhage
In emergencies, O(-) blood is used for
women of child-bearing age.
O(+) blood is used for men and
postmenopausal women.
Additional platelets and clotting factors are
give when large amounts of blood is needed.
Control of External Hemorrhage
Physical assessment is done to identify area
of the hemorrhage.
Direct, firm pressure is applied over the
bleeding area or the involved artery.
A firm pressure dressing is applied, and the
injured part is elevated to stop venous &
capillary bleeding if possible.
If the injured area is an extremity, it is
immobilized to control blood loss.
Control of Bleeding: Tourniquets
Applied only as a last resort just proximal to
the wound and tied tightly enough to control
arterial blood flow; tag the client with a T
stating the location and the time applied
Loosened periodically to prevent irreparable
vascular on neuro damage
If still with arterial bleeding, remove
tourniquet and apply pressure dressing
If traumatically amputated, the tourniquet
remains in place until the OR.
Control of Internal Bleeding
Watch out for tachycardia, hypotension, thirst,
apprehension, cool and moist skin, or delayed
capillary refill.
Packed RBC are administered at a rapid rate,
and the patient is prepped for OR.
Arterial blood is obtained to evaluate
pulmonary perfusion & to establish baseline
hemodynamic parameters
Patient is maintained in a supine position and
closely monitored.
Hypovolemic Shock
Compiled Notes of Bernie C. Butac
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Incised Wound
A clean cut by a sharp edged object such as
glass or metal.
As the blood vessels at the wound edges are
cut straight across, there may be profuse
bleeding
Laceration
Abrasion
Superficial wounds that occur at the surface
of the skin.
Friction burns and slides can cause abrasion
Characteristic in the way that only the top
most layer of the skin is scrapped off.
Bleeding is not profuse though wounds
Puncture Wound
Small entry site
Though not large in surface area, wounds are
deep and can cause great internal damage.
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Procedure:
1. One hand is placed distal to the fracture &
some traction is applied while the other
hand is placed beneath the fracture for
support.
2. The splint should extend beyond the joints
adjacent to the fracture.
3. Upper extremities must be splinted in a
functional position.
4. If a fracture is open, moist, sterile dressing
is applied.
5. Check the vascular status by assessing
color, temperature, pulse, and blanching
of the nail bed.
6. If there is neurovascular compromise, the
splint is removed and reapplied.
7. Investigate complaints of pain or pressure.
People at Risk:
those not acclimatized to heat
elderly and very young people
those unable to care for themselves
those w/ chronic & debilitating dse
those taking tranquilizers, diuretics,
anticholinergics, and beta blockers.
exertional heat stroke occurs in healthy
individuals during sports or work activities.
Heat Stroke
An acute medical emergency caused by
failure of the heat-regulating mechanisms.
Compiled Notes of Bernie C. Butac
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Pathophysiology
Hyperthermia results because of inadequate
heat loss, which can also cause death.
Most heat-related deaths occur in the elderly,
because their circulatory systems are unable
to compensate for the stress imposed by heat
Elderly people have ability to perspire as
well as a thirst mechanism to compensate
for heat.
Assessment
Causes thermal injury at the cellular level,
resulting to widespread damage to the heart,
liver, kidney, and blood coagulation
Watch out for profound CNS dysfunction
(confusion, delirium, bizarre behavior, coma),
body temperature (>40.6C), hot, dry skin,
anhidrosis, tachypnea, hypotension, and
tachycardia.
Management
The primary goal is to reduce the high
temperature as quickly as possible, because
mortality is directly related to the duration of
hyperthermia.
Simultaneous treatment focuses on stabilizing
oxygenation using the ABCs of basic life
support.
After clothing is removed, core temperature is
reduced to 39C ASAP by one or more of the ff
methods:
1. Cool sheets & towels or continuous
sponging with cool H2O
2. Ice applied to neck, groin, chest, &
axillae while spraying with tepid
water; cooling blankets
3. Iced saline lavage of stomach or
colon if temperature does not
decrease
4. Immersion in cold water bath
Nursing Interventions
Monitor vital signs, ECG, CVP and level of
responsiveness
Administer 100% oxygen to meet tissue needs
exaggerated by the hypermetabolic condition.
NSS or LRS is initiated to replace fluid losses
and maintain circulation
Urine output is monitored to detect acute
tubular necrosis from rhabdomyolysis.
Nurse Teachings
Advise client to avoid immediate exposure to
high temperature (10am-2pm).
Emphasize importance of adequate fluid
intake, wearing loose clothing, and reducing
activity in hot weather.
Monitor weight and fluid losses during
workouts; replace fluids
Use a gradual approach to physical
conditioning; allow acclimatization
FROSTBITE
Trauma from exposure to freezing
temperatures that results to actual freezing of
the tissue fluids in the cell and intracellular
spaces
Results in cellular and vascular damage
Body parts most frequently affected are the
feet, hands, nose and ears
Ranges from 1st (erythema) to 4th degree (fulldepth tissue destruction)
Assessment
Frozen extremity may be cold, hard, and
insensitive to touch
Appears white or mottled blue-white
Extent of injury from exposure to cold is not
initially known; assess for concomitant injury
History includes environmental temperature
duration of exposure, humidity, and presence
of wet conditions
Management
The goal is to restore normal body
temperature; controlled yet rapid rewarming
is instituted
Constrictive clothing and jewelry that could
impair circulation are removed.
Patient should NOT be allowed to ambulate if
the lower extremities are involved.
Place extremity in a 37 to 40C circulating
bath for 30- to 40-min.
Repeat treatment until circulation is
effectively restored.
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Hypothermia
A condition in which core temperature is 35C
or less as a result of exposure to cold
Occurs when patient loses ability to maintain
body temperature
Urban hypothermia is associated with a high
mortality rate affected are the elderly, infants,
patients with concurrent illnesses, and the
homeless.
Alcohol ingestion susceptibility due to
systemic vasodilation.
Trauma victims are at risk resulting from
treatment with cold fluids, unwarmed oxygen,
and exposure during examination.
Hypothermia takes precedence in treatment
over frostbite.
Assessment
Watch out for progressive deterioration, with
apathy, poor judgment, ataxia, dysarthria,
drowsiness, pulmonary edema, acid-base
abnormalities, coagulopathy & coma
Shivering may be suppressed below 32.2C
due to ineffective mechanism
Peripheral pulses are weak and become
undetectable; cardiac irregularities,
hypoxemia and acidosis may occur.
Management: Monitoring
VS, CVP, urine output, arterial blood gas
levels, blood chemistry and chest xray are
frequently evaluated.
Body temp is monitored with a rectal,
esophageal, or bladder thermometer.
Continuous ECG monitoring is done because
cold-induced myocardial irritability can lead to
v. fibrillation.
Pathophysiology
Fresh water aspiration results in loss of
surfactant, hence the inability to expand the
lungs.
Salt water aspiration leads to pulmonary
edema from the osmotic effects of the salt
within the lungs.
Treatment Goals
Maintaining cerebral perfusion and adequate
oxygenation to prevent further damage to
vital organs
Immediate CPR is the factor with the greatest
influence on survival
Prevention of hypoxia by ensuring an
adequate airway and respiration, thus
improving ventilation and oxygenation
Compiled Notes of Bernie C. Butac
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Management
ABG analyses are performed to evaluate O2,
CO2, HCO3 and pH
If the patient is not breathing spontaneously,
ET intubation with positive-pressure
ventilation improves oxygenation, prevents
aspiration, and corrects intrapulmonary
shunting and V-P abnormalities
If the patient is breathing spontaneously,
supplemental O2 may be given by mask
Because of submersion, the patient is usually
hypothermic; use a rectal probe to assess
Prescribed warming procedures such as
corporeal rewarming, warmed PD, inhalation
of warmed aerosolized O2, and torso warming
depends on the severity & duration of
hypothermia.
Intravascular volume expansion & inotropic
agents are used to manage hypotension &
impaired tissue perfusion; ECG monitoring is
done to monitor dysrhythmias.
A Foley catheter is used to measure output;
NGT intubation is used to decompress the
stomach & prevent aspiration of gastric
contents.
Close monitoring continues with serial VS,
serial ABGs, ECG monitoring, ICP
assessments, serum electrolyte levels, I & O,
& serial CXR.
Complications include hypoxic or ischemic
cerebral injury, ARDS, pulmonary damage 2
to aspiration, & cardiac arrest.
Decompression Sickness (DCS)
Occurs in patients who have engaged in
diving, high-altitude flying, or flying in a
commercial aircraft 24 hrs after diving
Results from nitrogen bubbles trapped in joint
or muscle spaces, resulting in musculoskeletal
pain, numbness, & hyperesthesia
Bubbles can become emboli in the
bloodstream & cause stroke, paralysis, or
death.
A rapid history & recompression is done ASAP
& may necessitate a low altitude flight to the
nearest hyperbaric chamber.
Assessment
Evidence of rapid ascent, loss of air in the
tank, buddy breathing, recent alcohol intake
or lack of sleep, or a flight within 24 hours
after diving are risk factors.
Signs and symptoms:
1. Joint/extremity pain
2. numbness, hypesthesia
3. loss of ROM
4. neuro Sx mimicking CVA
5. CP arrest in severe cases
Management
A patient airway and adequate ventilation are
established & 100% O2 is given throughout
treatment & transport
A CXR is obtained to identify aspiration, and
at least 1 IV line is started with LRS or NSS.
If a head injury is suspected, the head of the
bed is lowered.
Wet clothing is removed and the patient is
kept warm.
Anaphylaxis
An acute systemic hypersensitivity reaction
that occurs w/in seconds or min. after
exposure to foreign substances such as
medications & other agents
Repeated administration of oral & parenteral
therapeutic agents may cause this when
initially only a mild allergic response occurred
Pathophysiology
Antigen-antibody interaction
Antigen allergen
Antibody IgE previously sensitized basophils
and mast cells
Release of mediators like histamine and
prostaglandin cause the systemic reactions
Causes
Penicillins most common
Contrast media
Bee stings
Food
Anaphylaxis Signs and Symptoms
1. Respiratory Signs:
nasal congestion
itching, sneezing, coughing
bronchospasm & laryngeal edema
chest tightness, dyspnea
wheezing & cyanosis
2. Skin:
flushing with sense of warmth & diffuse
erythema;
generalized itching over entire body
(systemic reaction)
urticaria (hives);
massive facial angioedema (with
accompanying upper respiratory edema)
3. Cardiovascular:
Tachycardia or bradycardia
Peripheral vascular collapse
indicated by pallor, imperceptible
pulse, BP, circulatory failure,
coma & death
4. GIT:
nausea & vomiting
colicky abdominal pains, diarrhea
Anaphylaxis Management
Establish an airway & ventilation while
another gives epinephrine.
Early ET intubation avoids loss of the airway,
& oropharyngeal suction removes secretions.
If glottal edema occurs, a crico-thyroidotomy
is used to provide an airway.
Anaphylaxis: Epinephrine Administration
Subcutaneous injection for mild, generalized
symptoms
Compiled Notes of Bernie C. Butac
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CO Poisoning Management
Goal: to reverse cerebral and myocardial
hypoxia and hasten elimination of CO by:
1. Carrying the patient to fresh air
immediately and opening doors and
windows
2. Loosening all tight clothing
3. Initiate CPR if required; give O2.
4. Prevent chilling; wrap in blankets.
5. Keep patient as quiet as possible.
6. Do NOT give alcohol in any form.
7. Upon arrival at the ER, analyze
carboxyhemoglobin levels and give 100%
O2 until level is <5%.
8. Watch out for psychoses, spastic paralysis,
ataxia, visual disturbances, and
deterioration in mental status and
behavior which may be symptoms of brain
damage.
9. If accidental poisoning occurs, the DOH
should be informed so that the dwelling
could be inspected.
Food Poisoning
A sudden illness that occurs after ingestion of
contaminated food or drink
Some of the most common diseases are
infections caused by bacteria, such as
Campylobacter, Salmonella, Shigella, E. coli
O157:H7, Listeria, and botulism
Campylobacter
A bacterium that causes acute diarrhea
Transmitted through ingestion of
contaminated food, water, or unpasteurized
milk, or through contact with infected infants,
pets or wild animals.
Salmonella
Transmitted by drinking unpasteurized milk or
by eating undercooked poultry and poultry
products such as eggs
Any food prepared on surfaces contaminated
by raw chicken or turkey can also become
tainted
May also stem from food contaminated by a
food worker
Shigella
Transmitted through feces. It causes
dysentery, an infection of the intestines
causing severe diarrhea. The disease
Assessment
1. How soon after eating did the symptoms
occur?
2. What was eaten in the previous meal? Did
the food have an unusual odor or taste?
3. Did anyone else become ill from eating the
same food?
4. Did vomiting occur? What was the
appearance of the vomit?
5. Did diarrhea occur?
6. Any other neurologic symptoms?
7. Does the patient have a fever?
8. What is the clients appearance?
Management
Determine the source and type of food
poisoning.
Food, gastric contents, vomitus, serum and
feces are collected for examination.
Patients VS, sensorium and muscular activity
are closely monitored.
Support the respiratory system and assess
fluid and electrolyte balance; watch out for
Compiled Notes of Bernie C. Butac
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Burns
Alteration in skin and underlying tissues as a
result of:
Too much exposure to sun and UV
Direct contact with heat and burning
object
Hot water and liquids
Chemicals
Part of the Body Burned
Special attention to the hands, head, neck,
chest, ears, face, perineum and feet
Prevention of contractures in these areas is
crucial to good healing.
Any time there is soot around the nose or
mouth, burned nasal hairs, stridor,
hoarseness, decreased breath sounds, upper
airway damage should be suspected.
Burns in the Extremes of Age
In pediatric clients under age 2, the
immunologic response to stress and trauma is
not fully developed, and a burn injury can be
overwhelming.
In the elderly, these responses are diminished
and the person's general health may be
compromised by existing medical problems.
Burn Management
Maintenance of Airway Patency
A. Assess the airway.
B. Auscultate the trachea, and monitor for
adventitious breath sounds or decreased
breath sounds.
C. If client is dyspneic or if there is carbon
monoxide poisoning, a high liter flow of 8
to 10 liters of oxygen is recommended.
D. If compromise is suspected, the victim
may be intubated and ventilated.
Indications for intubation are
airway obstruction and a PaO2 of
less than 60 mm Hg.
The continuous monitoring by
means of a pulse oximeter assists
in assuring adequate oxygenation.
E. The client's level of consciousness should
be carefully monitored. Burn victims are
most often alert, oriented and cooperative
even with extensive injuries.
Fluid Resuscitation
The maximum loss of fluid occurs within 12 to
18 hours after the burn.
The total quantity of fluid required to correct
this volume deficit is replaced in the first 24
hours following the burn injury.
The amount of fluid required to correct the
deficit is calculated to be 2 to 4 mL per cent
burn per kilogram of body weight.
Administration of the fluids takes place over a
24-hour period with half the amount given in
the first 8 hours and the remainder over the
next 16 hours.
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3. Parkland Formula
Lactated Ringers Solution: 4 mL x
body weight (kg) x % BSA burned
Day 1: Half to be given in first 8 hours;
half to be given over next 16 hours
Day 2: Varies. Colloid is added (e.g.
albumin, dextran)
Burn Management
Obtain laboratory data
Monitor urine output and vital signs
Administer tetanus antitoxin/toxoid
Hypertonic Saline Solution
Goal: to increase serum sodium level and
osmolarity to reduce edema and prevent
pulmonary complications
Concentrated solutions of sodium chloride
(NaCl) and lactate are given sufficiently to
maintain a desired volume of urinary output.
Phases of Burn Care: Emergent
1. Airway
2. Breathing
3. Circulation
4. Disability
5. Exposure
6. Fluid Resuscitation
Management
The skin should be continuously drenched
immediately with running water from a
shower, hose or faucet as the patients
clothing is removed.
The skin of the health care professional
assisting should also be appropriately
protected.
Chemical Poison Warnings
Water should NOT be applied on burns from
lye or white phosphorus because of a
potential for an explosion or for deepening of
the burn.
All evidence of these chemicals should be
brushed off the patient before any flushing.
Management
Determine the identity and characteristics of
the chemical agent for future treatment.
The standard burn treatment for the size &
location of the wound (antimicrobials,
debridement, tetanus toxoid) is instituted.
The patient may require plastic surgery for
further wound management
The patient is instructed to have the affected
area re-examined at 24 & 72 hours and in 7
days because of the risk of under-estimating
the extent & depth of these types of injuries.
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