Emergency Nursing

2.

Patient
Assessment,
Reporting
and
Documentation
Principle 2 rapid, accurate initial patient
assessment and precise reporting and
documentation, whether in the pre-hospital or
hospital settings are keys to effective patient
care
Role of nurses..
1. Verify that the scene is safe and
secure
2. Be an astute observer
3. Information gathered must be
communicated
4. Record
other
pertinent
information of the patient
5. Provide explanation for omissions of
care (for purposes of law suits).
6. Record detailed triage notes
Triage notes:
How the patient was brought
to the hospital (ambulatory,
brought by private vehicle,
conscious)
Interventions initiated by
EMT-Basics
Medications given by the
EMT-Paramedics (advanced
cardiac life support)
EMT-Intermediate
(performs basic life
support and some
interventions
in
advanced cardiac life
support)

3.

Patient and Family Education

Principle 3patient and family education is
the responsibility of every ER nurse
Role of nurses
1. Provide effective, individualized
instruction re: home care
2. Identify learning needs
3. Establish realistic goals
4. Allow for learning time
5. Evaluate the results
6. Document the instruction

fast, quick, rapid

time is of essence

Emergency- any sudden illness or injury which is

perceived by the significant others and/or patient as
requiring immediate medical attention
Emergency Nursing

care given to situations needing immediate

medical interventions
care of individuals of all ages with
perceived or actual physical or emotional
alterations of health that are undiagnosed or
that require further interventions
It is episodic (at any time, not constant),
primary (immediate, NO restorative or
rehabilitative) and usually acute (patients
are wheeled out after care is given)

Scope of Emergency Nursing

A- Ssessment
D- iagnosis
T- reatment
E- valuation (for as long as the patient is
stable)
Principle of Emergency Medical Treatment
1.

Communicating in Crisis
Principle 1patients need to know that their
feelings are accepted and acknowledged by the
ER personnel
Role of nurses
1. Give verbal and nonverbal
2. Inform patients (what and why is
it to be done)
Physicians responsibility- (1)
obtain informed consent, (2)
explains any invasive procedures
to patient
3. Be aware of ones own feelings
(self-assessment)
4. Talk with patients
5. Encourage patients to discuss
opinions (e.g. delivery of care)
6. Help
patients
verbalize
frustrations
7. Offer realistic hope
8. Be honest

P. Chan 2017

Other Basic Principles in Emergency care

1.

Provide for basic survival needs and

comfort

2.
3.
4.
5.
6.

7.

Help survivors achieve restful and

restorative sleep
Provide privacy
Provide non-intrusive ordinary social
contact
Address immediate physical problem
Assist in locating and verifying the
personal safety of separated loved ones
and friends
Help survivors take practical steps to
resume ordinary day to day life

2.

3.
Basic Legal Issues
A. Consent (permission to care) to treatment
1. Expressed (verbal or/and writing)-freely
and voluntary given
2. Implied-presumed consent
3. Involuntary-patient refuses care and an
individual gives consent (e.g. SO)
4. Informed-given provided that proper
explanation has been done
3 Essential components of Informed
Consent:
The physician must
Describe the procedure to
be performed
Explain the alternatives
available to the procedure
Detail the risks of the
procedure
When does an informed consent become valid?
Legal age 18
Mentally stable
Information communicated in the
language known to the consente
Emergency Doctrine (implied consent)
-

Implies that the client would have

consented to treatment if able, because the
alternative would have been death or
disability
Provides and exemption to obtaining
informed consent before a procedure is to
be done

Consent Dilemmas
1.

Minors

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Emancipated minors (economically

independent, married)
Refusal to consent based on religious
conviction
General rule-patient can refuse care on
the ground of religious convictions
Exceptions- (1) social circumstances, (2)
court order e.g child who needs blood
transfusion of whom both parents are
Jehovas witness, the court must have the
final say
Refusal of treatment leaving against medical
advice

Patient self-determination Act (1991)

- Provides hospitalized patients with the ability to
decide regarding their wishes for termination or
continuation of life support
E.g.
a. Durable Power of Attorney
Attorney-in-fact (could be SO)
- Things to be done are
the ones specified in
the document signed
by a conscious patient
b. Living wills
- a
written
statement/document
detailing the patients
desires regarding their
medical treatment in
circumstances in which
they are no longer able
to express informed
consent.
c. Do not resuscitate order (DNR)
- Legal document signed
by the patient and his
physician, which states
that the patient has
terminal illness and does
not wish to prolong life
through
resuscitative
efforts
- Also called an advance
directive
What are good Samaritan laws?
- Laws which are passed in order to
encourage lay persons or all persons

present in emergency situations without

fear of liability with regard to care given
E.g Broken ribs caused by inappropriate
performance of CPR by a nursing
student=good Samaritan laws cannot be
invoked
E.g patient has incurred bruises (as long as
it is NOT a major complications=good
Samaritan law can be invoked)
Effect of help should not be graver than
the condition of the patient

Patient Transfer Issues

Emergency Medical Treatment and Active
Labor Act (EMTALA)
(Before) Consolidated Omnibus
Budget
Reconciliation
Act
(COBRA)
Laws
governing
patient
with
regarding to dumping or transferring
to one hospital to another because of
inability to pay
EMTALA Highlights
1. All individuals
2. To determine the existence of an
emergency medical condition, there
must be: threat to life or limb, or
severe pain, or active labor
- Duty
to
provide
AMS
(Appropriate Medical screening)whether patient is on an
emergency situation
3. Hospitalized
with
specialized
capabilities must accept transfers if
with capacity to treat
4. Transfers require:
consent of patient
accepting physician
accepting facility
appropriate vehicle
appropriate equipment
qualified personnel
records must accompany the
patient
Principle of Confidentiality
not entitled to spread/share
information to persons not
directly involve to the care of
patient
Exemptions:
- Public interest is at stake
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Criminal cases
Consent of patient to reveal
information
Sued for damages (content
of patients chart is the very
thing in issue)
* Case of support is not a
criminal case.

More of legal issues

Documentation
Reportable conditions report crimes to
appropriate
agencies,
conditions
mandated by laws, doctors and nurses
has equal responsibility
Note: report the condition even if you
dont have consent from the doctor
Discharge instructions- written and oral
Physical evidence and chain of custody
- Bullets
- Blood specimens/blood samples
Note: patient should not be force to
undergo blood examinations (forcing
would mean assault); exemptions
principle of confidentiality
Organ donation-brain death has been
pronounced by the doctor; signed a legal
consent
Roles in Emergency Nursing
1. Triage Nurse
2. Telephone Advice Nurse
3. Poison Control Specialist
4. Transport Nurses
5. Trauma Nurse Coordinator
6. Pediatric ED Nurse
7. Case Manager
8. EMS Liason
9. Nurse Practitioner
10. Clinical Nurse Specialist
General Responsibilities of Emergency Nurses
1. Works in an area staffed and equipped for
the reception and treatment of persons
with conditions requiring immediate
medical care, serious illness and trauma
2. Efficiently do A-P-I-E
Responsibility During Death and Dying
1. Provide ample opportunity to the patient and
family to be together
2. Allow presence of family members during
resuscitation

3.
4.
5.
6.

7.
8.
9.

Provides religious support

Communicate honestly about the patients
condition
Encourage viewing the body in instances of
sudden death or trauma
Because preservation of legal evidence is often
important in sudden death, SO are advised
beforehand of the various tubes and devices
present.
Determine clients wishes re: organ donation
May provide a follow-up telephone call to SO not
present re: their questions or concerns
Make referrals to support groups

Disaster Nursing
Disaster- any situation, natural or manmade
that produces an immediate patient load
greater than the normal ED can handle
Mass Casualty Incident
- Any time an incident or disease occurs
that leaves many people ill or injured
- Can be caused by natural ( i.e.
earthquakes, floods) or accidental or
intentional disasters (terrorist attacks,
sarin gas release)
Classification of MCI
1. Level I- involves more than 100
patients
2. Level II- involves greater than 50 but
not more than 100 patients
3. Level III- greater than 25 but not more
than 50
4. Level IV-greater than 10 but not more
than 25
5. Level V-an incident involving no more
than 10 patients
6. MCI (contamination)
- an MCI of any level, which
includes or has the potential for
biological,
chemical
or
radiological contamination
Note:
Common on all levels:
-Having a great impact on
the emergency department and going
beyond the capacity to treat
Categories of Disaster:
1. Class A (all require response by hospital disaster
team); bigger impact
- Natural disasters: earthquakes, floods,
tornadoes
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2.

3.

External disasters/medical emergencies:

chemical exposure, epidemic of disease,
nuclear fall-out
Class B
- Internal disasters/medical emergencies
that may require response by hospital
disaster team or specially created crisis
team
- Death of key personnel (pope, president),
large scale poisoning, death of religious
personnel
Class C
- Internal
disasters/non-medical
emergencies
- May require response by hospital disaster
team or specially created crisis team
- Bomb threats, strikes, criminal activity
(rape, kidnapping, shooting)

Phases /Stages of Disaster

1. Pre-impact/preparedness
- Occurs prior to the onset of the disaster
- Not all type of disasters has the pre-impact
phase
2. Impact/response
- Disaster
occurs,
continuing
to
immediately following disaster (brief or
lasing to few hours)
- Inventory and rescue period
- Assessment of the extent of the losses,
planning on how to use the resources left
and how to rescue the victims
3. Post-impact/recovery
- Majority of rescue operations
- Remedy and recovery period
- Lengthy phase and may last for years
1. Honeymoon
phase-feelings
of
euphoria
2. Disillusionment-anger,
disappointment
3. Reconstruction phase-acceptance of
loss, coping stress, rebuilding
DISASTER PLAN
A predefined set of instructions
for a communitys emergency
responders
Features of a good disaster plan
1. Written
2. Well-publicized
3. Realistic
4. Rehearsed

Key components of Disaster Plan

1. Patient care
System on how to receive
and
distribute
patients
whether incoming/evacuated
patients
Triage procedure
Provides care for the greatest
number (NOT applicable in
non-disaster triage)
Avoid treating ambulatory
patients
as
dependent
patients
Pre-assignment with regard
to responsibillity
2. Communication
Internal: within personnel
External:
one
hospital
facility to another
3. Resources-staff
Disaster team must know
how to contact the resource
staff
4. Security/ Safety ensure the
scene is safe
5. Coordination
with
Public
Agencies
6. Documentation
7. Public relations- officials
8. Critical
Incident
Stress
Debriefing
- NOT
a form of
psychotherapy
- Done
to
mitigate
(lessen)
the
occurrences of PTSD
- Group
process
involving persons who
are victims/ survivors
of an overwhelming
event
or
trauma
including those who
may
have
been
impacted by the trauma
- Aims to prevent the
subsequent
development of PTSD
- Provides avenue for the
patient
to
express
feelings,
coping
P. Chan 2017

mechanisms,
learned

lessons

Disaster Management Principles

1. Prevent occurrence
2. Minimize casualties
3. Prevent further casualties
4. Rescue the injured
5. Provide first aid
6. Evaluate the injury
7. Provide definitive care
8. Facilitate reconstruction and recovery
The responsibility of nursing care
vary (depends on situation or
available resources)
May include triage, patient care,
equipment,
directing
others,
recording, transportation
What are the psychological and emotional
responses to emergency and disaster?
Immediate reactions (anxiety, frustration,
anger, physical symptoms)
Delayed reactions (feelings of loss, grief and
guilt, flashbacks, nightmares)
Nursing Interventions:
A. For immediate stress reaction
1. 5 minutes break at least every hour
2. Monitor for shaking, trembling, loss
of coordination
3. Provide rest area
4. Rotate frontline personnel
B. For delayed reaction
1. 2 mandatory debriefing sessions
2. Encourage liberal leave policy
3. Begin stress management class
Triage System
- trier to sort
Triage Nursing
- care given to patients to ensure that those
requiring immediate attention for life
threatening emergencies receive it
- first used during Napoleonic war
Primary goal of an effective triage:
- RAPID identification of patients with urgent,
life threatening conditions
Complementary goals of an effective triage:
1. Prioritizing care needs for all patients

2.
3.

Regulating patient flow through ED

Determining the most appropriate area for
treatment- the ED or an outside primary care
area

Note:

The triage models in disaster

those patients who are severely injured and are
unlikely to survive despite medical attention
would receive the lowest priority triage.
(greatest good for the greatest number)
The triage model in emergency nursing
Priority is those patients who are in severe
condition
Triage Models
Triage tags refers to color coding, identification to
each injured patient; for priority, save time
A. Non-disaster Triage models
-i.e. models for individual triage: traffic
director; spot check; comprehensive
Purpose: to provide best care for each individual
patient.
A.1. Models for individual triage
a.1.1. Traffic director
categories: emergent (life-threatening
and major illness) & non-urgent
(treatment can be delayed)
sometimes done by unlicensed person
assessment consist of chief complaints
disadvantage: emergent patients are
disregards due to mixed with
nonemergent patients
sort to acute care or waiting room

no further evaluation by triage (retriage)

when used
1. low daily census
2. no waiting period for patients to
see licensed health care
professional
a.1.2. Spot Check
categories: emergent (life
threatening), urgent (major illness),
delayed (patient may be treated or
treatment may be delayed for more
than 20 hours)
assessment by RN or MD
no planned reevaluation
P. Chan 2017

when used
1. high patient census
2. waiting period is anticipated

a.1.3. Comprehensive Triage

categories: life-saving (multiple
trauma; assessment is continuous);
stable but urgent (sickle-cell,
fractures; every 15 min); stable but
non-urgent (small laceration; every
30 min); stable, may wait indefinitely
for care (abrasion, impetigo; every 60
min)

assessment done by RN
patients who remain in the waiting
room are re-assessed every 15-60min
depending on severity of illness or
injury

when used
1. high patient census
2. treatment space limited
B. Multi-casualty/Disaster Triage Model
Purposes: to provide the most effective care for the
greatest number of patients
Sample models for Multi-casualty/disaster triage model
b.1.1. Simple
categories: immediate care (multiple
traumas, inhalation injuries); delayed
care (extremity fractures, minor
burns)
b.1.2. Military
5 level triage system
Categories
1. Immediate (I)
triage tag: red
life-threatening injuries that
probably survivable with
immediate treatment
i.e. tension pneumothorax,
respiratory distress, airway
injuries, shock
2. Delayed (II)
triage tag: yellow
treatment may be postponed
without loss of life
i.e. minor extremity fractures,
lacerations with hemorrhages
controlled
3. Minimal
triage tag: green

little or no professional care

required
ambulatory, can self-treat or seek
alternative medical attention
independently
i.e. minor lacerations, abrasions

Categories:
1. Priority (0)
tagged as black; patients not
breathing and have no pulse
evacuation: leave where they fell
attempt to open airway to assess
respiration and pulse

4. Expectant (0)
triage tag: black
have lethal injuries and will die
despite treatment
i.e. devastating head injuries,
destruction of all vital organs

2. Priority (1) immediate

tagged as red; patients who have
R - > 30 cpm
P absent radial pulse
M altered
used in evacuation: by MEDEVAC
or ambulance

5. No apparent injuries
triage tag: white
b.1.3. Disaster ((4 level triage))
* Categories
1. Emergent
triage tag: red
critical life threatening; patient is
expected to live; shock; airway
problems
2. urgent
triage tag: yellow
major illness/injuries should be
treated within 20min 2 hours;
i.e. open fractures, chest wounds
3. non-urgent
triage tag: green
minor injuries, usually
ambulatory; are maybe delayed
for more than 2 hours; i.e., closed
fractures, sprains
4. Dead or with impending death
Triage tag: black
slim to no chance of survival;
shouldnt take priority over
salvageable patient; i.e., massive
trauma, extensive 3rd degree
burns

3.
Priority (2) delayed
tagged as yellow
R < 30 cpm
P have radial pulses present
M alert
evacuation: delayed until all immediate persons have
been transported
4.

Priority (3) minor

tagged as green
walking wounded
evacuation: not evacuated until all
immediate & delayed persons have
been evacuated
2.) Advanced triage-similar to military
- implemented by skilled nurses
* Categories:
1.

Other Triage Models

1.) START ((simple triage and rapid treatment))
can be performed by lightly trained
lay & emergency personnel in
emergencies
physiologic parameters: RPM
R respiration
P pulse
M mental
P. Chan 2017

Expectant (black)

2.

3.

severely injured with life threatening

medical crisis unlikely to survive
given with care available
should be taken to a holding area and
given pain killers
cardiac arrest; septic shock
not used in ER
Advance cardiac life support

Immediate (red)
immediate surgery, cannot wait but
likely to survive (i.e. tension
pneumothorax)
Observation (yellow)
stable for the moment but requires
watching and frequent re-triage (i.e.

laceration with controlled

hemorrhage)
4.

5.

Wait (green)
walking wounded
required doctors care in several
hours or days but not immediately,
maybe told to go home and come
back home within the next day
i.e. broken bones without compound
fractures, soft tissue injuries
Dismiss (white)
walking wounded with minor injury,
do not require doctors care
i.e. small cuts, scrapes

- head to toe assessment : 90 seconds

* Focused Assessment
- diagnostic procedures
1. ECG
2. lab studies
3. radiology
CARDIOPULMONARY ARREST
-

with patients heart, circulation, and respiration

suddenly cease
Causes:
a. Metabolic
a.1. hypoglycemia
a.2. hyperkalemia
b. Drug-induced
c. Pulmonary
d. Neurologic
e. Hypovolemic
f. Other cardiac causes

STEPS IN TRIAGE
1. Primary survey
consist of ABC
consist of ABCD proposed by
ENA
A Airway
B Breathing
C Circulation
D Disability (neurologic assessment status)
E Exposure or environment (coldness or hotness)

a.

AVPU (a very practical use)

A alert
V voice
P pain (response)
U unconscious/unresponsive
Secondary survey
follows primary survey and is very brief
use SAMPLE (S signs and symptoms;
A allergies; M medications; P
pertinent past history; L last oral
intake, E events leading to problem)
- AMPLE
- a crash plan

P atrial contraction
QRS ventricles contract to pump out blood
ST time when the ventricles end of
contraction and beginning of the T wave
T time of repolarization

2.

A airway/breathing
C cardiovascular
R respiratory
A abdominal
S spinal
H head & EENT
P pelvis
L legs
A arteries (pulses)
N nerves
P. Chan 2017

Metabolic causes
a.1. hypoglycemia
s/s: unconsciousness,
tachydysrhythmias, seizures,
aspiration, weakness
mgt: 50% dextrose
a.2. hyperkalemia
s/s: ECG (prolonged Q-T interval;
peaked T wave; wide QRS complexes
mgt: calcium chloride; sodium
bicarbonate

b.

Drug- Induced
b.1. TCAs (e.g. amitryptyline)
s/s: tachydsyrhythmias
mgt: sodium bicarbonate alkylating
agent
b.2. Narcotics
s/s: bradydysrhythmias; heart blocks
mgt: naloxone (Narcan)
b.3. Propanolol
s/s: cardiac: bradydysrhythmias;
respiratory: bronchospasm; metab:
hypoglycemia
mgt: for bradydysrhythmias: Isuprel,
Atropine

for bronchospasm: aminophylline

for hypoglycemia: 50%dextrose
c.

Pulmonary
c.1. asthma
s/s: severe bronchospasm,
tachydysrhythmias
mgt: endotracheal intubation and
ventilatory support
c.2 pulmonary embolus
s/s: pleuritic chest pain, SOB,
tachydsyrhythmias
mgt: good ventilatory support
c.3. Tension pneumothorax
s/s: distended neck veins, tracheal
deviation, asymmetric chest
expansion
mgt: needle thoracotomy, chest tube

d.

e.

f.

Neurogenic
d.1. increased ICP from any causes
s/s: dilated pupils, decerebratedecorticate posturing, dysrhythmias
mgt: steroids, diuretic agents, surgery
i.e Mannitol: MIO monitoring; soluset
used, risk for cardiopulmonary edema
Hypovolemia
e.1 anything that causes volume loss of
blood
s/s: tachycardia, decreasing bp, cool
clammy skin
mgt: IV fluids, PASG (Pneumatic
anti-shock garment), shock position
PASG is contraindicated in the ff:
Cardiopulmonary edema
Severe chest injuries even
patient is in shock
Pregnant woman: do not
cuff abdomen
Other cardiac causes
f.1 Pericardial tamponade
s/s: distended neck veins, decrease BP,
bradydysrhythmias, widening pulse pressure
mgt: IV fluids, atropine, Isuprel, thoracotomy

Chain of survival
1.
2.
3.
4.

Early access
Early CPR
Early defibrillation
Early advance care

Basic Life support

P. Chan 2017

Survey the scene

(Scene is safe, crowd controlled)
Introduce self
Activate the EMS (Emergency Medical Services)
-Call the ambulance
Check for consciousness
L-ook
L-isten
F-eel
Hey, hey are you ok?
Give 2 initial breaths. Continue on LLF.
Check pulse. Brachial-infant; carotid-adult
If pulse and respiration is absent, do 30 cycles of chest
compressions: 2 breaths
Wait for the automated external defibrillator
AED
Check if shockable
shockable
Ventricular tachycardia,
ventricular defibrillation

Check if not

Asystole also called

ventricular stand still,
pulseless electrical
activity (no blood to be
pumped)

Deliver 1 shock using AED.

C-L-E-A-R.
-Nobody is touching the patient.
-No metallic objects.
-Not on wet ground.

Cannot perform
defibrillation.
Repeat CPR for 5
cycles until ACLS
arrives.

Repeat CPR for 5 cycles

Shockable refers to dysrhythmias which can
be subjected to defibrillation (electrical activity
of the heart is present
BLS can operate automated external
defibrillator
Ventricular tachycardia> 100 bpm

Nitroglycerine patches-dilates the vessel to encourage

blood to stay in the venous system
-less cardiac rate
Use gloved hand in detaching the plastic to prevent
headache.

P. Chan 2017

It will burst due to the electrical

activity being delivered
Position of patches:
Anterolateral position-most common
Anterior and posterior

CPR (5 cycles)

Wait AED

Advanced Cardiac Life Support (ACLS)

CPR (5 cycles)

If shockable

CPR (5 Cycles)

CPR (5 Cycles)

Administer the ff
antiarrhythmic drugs

Amiodarone

Lidocaine

Magnesium

Administer
Epinephrine (1 mg/IV)
Vasopressin (40 IU IV)
If epinephrine is
not the choice

Repeat CPR
for 5 cycles

Pulseless-no respiration

If not shockable
Give CPR for 5 cycles

If shockable

Administration of the ff:

1. Epinephrine (1
mg/IV) 3-5 minutes
2. Vasopressin 40
IU/IV
3. Atropine 1 mg/IV in

Deliver oxygen

AED
Monitor using ECG 12 -lead

3 doses
If not shockable

Give CPR for 5 cycles

Administration of the ff:
1. Epinephrine (1
mg/IV) 3-5 minutes
2. Vasopressin 40
IU/IV
3. Atropine 1 mg/IV in
3 doses

AED (1 shock)

AED (1 shock)

Administer 1
shock
(AED)

If
shockable

Difference between BLS and ACLS

- administration of drugs
0-4 min brain damage not likely
4-6 min brain damage is probable
6-10 min irreversible brain damage is possible
More than 10 min irreversible brain damage is certain

Complications of Cardioversion:
Asystole
PVCs (Premature ventricular contractions)
Ventricular tachycardia
Ventricular fibrillation
Return to atrial fibrillation or atrial flutter

Contraindication in Defibrillation

Drugs Commonly Used in Cardiopulmonary Resuscitation

1.
2.
3.
4.

Less than 1 year old (infants heart is normal, therefore the electrical
activity is normal)respiratory problems brought about by Foreign A
Body Obstruction and drowning are common causes among this age
If electrical activity is normal, no defibrillation should be given.
Patients with severe traumatic chest injuries
Hypothermic-no to defibrillation, warm the patient first before
applying defibrillation

Cardioversion
Synchronous electrical countershock timed to coincide with the QRS
Not delivered on the T (repolarization) wave (compromised delivery of
energy)
Differences:
Cardioversion

Defibrillation

-set in synchronous
mode
-sedate patient if
conscious
-hemodynamically
unstable

-set in
unsynchronous
mode
-patient is
hemodynamically
stable

Nursing Responsibility for Cardioversion:

1. Monitor V/S, LOC and cardiac rhythm frequently until patient is
hemodynamically stable and returns to pre-orientation LOC

Drugs

Classifications

1. Adenosine
(Adenocard)
2. Atropine
3. Bretylium (bretylol)
4. Epinephrine
(adrenalin)
5. Isoproterenol
(Isuprel)
6. Lidocaine
(xylocaine)
7. Procainamide
(pronestyl)
8. Sodium Bicarbonate
9. Verapamil (Calan,
isoptin)

Antiarrhythmias
Anticholinergic;
parasympathomimetic
Category 3
antidysrhythmias
Sympathomimetic drugs
Sympathomimetic drugs
Category 1B
antidysrhythmias
Category 1A
antidysrhythmias
Electrolyte , alkylating
agent in metabolic
acidosis
Calcium channel
blocker, category 4
antidysrhythmias

Commonly Used Parental Vasoactive Drug

Drugs

Classifications

1.
2.
3.
4.
5.
6.

Esmolol
(brevibloc)
Calcium chloride
Diazoxide
(hyperstat)
Diltiazem
(cardizem)
Dobutamine
(dobutrex)
Dopamine
(Intropin,
Dopastat)

Antidysrhythmias,
ACE inhibitors
Electrolytes
Antihypertensive drug
Calcium channel
blocker
Sympathomimetic
drugs
Sympathomimetic
drugs

Other Drugs in Cardiac Emergencies

Drugs
1.
2.
3.
4.
5.
6.

Enalapril
(Vasotec)
Labetalol
(Normodyne)
Nitroglycerine
(Tridil)
Nitroprusside
(Nipride)
Norepinephrine
(levophed)
Propanolol
(Inderal)

Classifications
ACE inhibitor
Alpha-adrenergic
blocker
Vasodilator
Vasodilator;
antihypertensives
Vasopressor;
adrenergic
Beta blockers

Morphine sulfate: emergency drug of MI

-reduces the preload thus decreasing the myocardial oxygen demand;
relieves pain
Phases of MI:

A. Ischemic phase- myocardial repolarization is altered and delayed

causing the T wave to invert
B. Injury phase-causes ST segment changes
-ST segment rises at least 1 mm measuring 0.08 seconds. If
the myocardial injury is on the endocardial surface, the ST segment is
depressed 1 mm or more at least 0.08 seconds
C. Infarction-abnormal Q wave is 0.04 seconds or longer
(Smeltzer & Bare, 2004, p. 726)

shock
-state of inadequate perfusion and oxygenation to vital organs and tissues
throughout the body
Vital Organs Affected by shock:
Brain
Heart
Kidneys
Liver
4 Stages of Shock:
1. Initial cellular level
- increase anaerobic metabolism; decrease aerobic
metabolism
- Increase lactic acid production= pain
- Decrease cardiac output
2. Compensatory
a. Renin-angiotension system
b. Sympathetic
- Release epinephrine (vasoconstriction)
c. Release of ADH (posterior pituitary gland)
d. Intracellular fluid shifts
3. Progressive
4. Refractory (Irreversible)
Types of Shock:
1. Hypovolemic shock
-caused by a decrease in circulating volume greater than 15 %
-s/s: initial stage: pain, tachycardia, skin dry and slightly moist, ABGs
normal

Compensatory stage: anxious, hypotension, cool, clammy skin,

may have metabolic acidosis
Progressive: confused, restless, agitated, profound hypotension,
cardiac dysrhythmias, skin pale, no purposeful movement
Irreversible: severe hypotension, tachypnea with shallow depth,
profound metabolic acidosis, comatose
2. Cardiogenic
Caused by abnormal cardiac functioning or pump failure
s/s: restless, agitated, hypotension, tachycardia with weak thread
pulse, decreased pulse pressure, skin cool and moist, JVD
3. Obstructive
-results from the inability of the ventricles of the heart to fill or empty
appropriately because of an obstruction in the blood flow from the
heart
-s/s: anxiety, hypotension, JVD, pallor, diminished or absent breath
sounds, tracheal deviation
4. Distributive
a. Anaphylactic shock-results from an overwhelming immune
response to the presence of an allergen or antigen
s/s: marked restlessness, difficulty swallowing or severe itching,
hypotension tachycardia
b. Septic shock-associated with endotoxic release of gram negative
bacteria in the blood stream
s/s: decreased BP, or normal BP with widened pulse pressure,
tachycardia, hyperventilation, positive cultures
c. Neurogenic shock-occurs as a result of decreased sympathetic
control of vasomotor responses
s/s: hypotension, bradycardia followed by tachycardia, pallor,
decreased to absent urinary output.

Emergency Care Steps For Shock:

1. Maintain an open airway and assess respirate
2. If with adequate breathing: apply high concentration oxygen by
nonrebreather mask.
3. Assist ventilation or perform CPR if necessary
4. Control bleeding
5. Apply and inflate the PASG
6. If with possibility of spine injury: elevate the legs 8-12 inches
7. Splint any suspected bone injuries or joint injuries en route to the hospital.
If in shock, place the body on a spine board.
8. Prevent loss of body heat
9. Transport patient immediately.
10. If patient is conscious, speak calmly, and reassuringly throughout the
assessment, care and transport
General Treatment Measures of Shock:
1. Follow ABC guidelines
2. Supine position with spinal alignment maintained
3. Airway should be secured, protected and supplemental oxygen should
be initiated through the appropriate delivery device dependent on the
clients overall assessment.
4. Initiate an IV access
5. Initiate continuous cardiac and Sa O2 monitoring and prepare doe
frequent, repetitive vital sign assessments
6. Maintain stabilization of all deformities and prevent hypothermia
7. Place an indwelling cath
8. Administer sympathomimetic drugs as ordered