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Crisis III
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Multiple Injuries
Definition: - Requires rapid and definitive intervention during the 1st hour after the trauma to chances of survival - This first hour has been called the golden hour - During this time, multiple assessment and intervention may be performed simultaneously by the heat care team
Primary Assessment
AIRWAY Assume a cervical spine injury and open the airway using the jaw-thrust technique without head tilt Apply suction to clear the trachea and bronchial tree. Remove debris from the mouth (i.e. broken teeth, mucus) Insert an oropharyngeal airway o To prevent occlusion by the tongue o Used in UNCONSCIOUS PATIENTS ONLY Prepare for endotracheal tube if adequate airway cannot be maintained If upper airway trauma / edema exist, a cricothyroidotomy may be indicated
Topics Discussed Here Are: 1. Continuation of Trauma: a. Multiple Injuries b. Shock and Internal Injuries 2. Environmental Emergencies a. Heat Exhaustion b. Heat Stroke c. Hypothermia 3. Behavioral Emergencies a. Violent Patients b. Depression c. Suicidal Ideation 4. Sexual Assault Rape 5. Biological Weapons a. Anthrax b. Small Pox c. Botulism 6. Toxicologic Emergencies a. Ingestion Poisoning b. Food Poisoning c. Injected Poisoning d. Skin Contaminated Poisoning / Chemical Burns e. Drug Intoxication / Abuse
BREATHING Note the characteristic and symmetry of chest wall motion and patter n of breathing o Assess for open wounds, deformity and flail segments Auscultate the lungs and assess for tracheal deviation. If a tension pneumothorax is present, the trachea will shift away from the injury Ask the conscious patient if experiencing difficulty in breathing / chest pain with breathing Administer O2 by 100% non-rebreather mask / assist the patient ventilators by bag-valve mask Suspend serious intrathoracic injuries if respiratory distress continues after adequate airway has been established Assess the overall effectiveness of ventilations CIRCULATION Assess cardiac function and treat cardiac arrest o Hypoxia, metabolic acidosis, and chest trauma may precipitate cardiac arrest o For cardiac arrest, start closed chest compression and ventilation Control Hemorrhage o Apply pressure over bleeding points if hemorrhage is overt Expect significant blood loss in patients with fracture to the shaft of the femur, multiple fracture or pelvic fracture Use tourniquet(s) for massive arterial bleeding from extremities that cannot be halted with pressure o This practices is controversial, however Prepare for immediate surgical intervention if patient is bleeding internally Prevent and treat hypovolemic shock o Insert at least 2 (sometimes 4) IV lines o Initiate central venous catheter to monitor the patients response to fluid infusion To prevent fluid overload and a route for fluid infusion o Fluid restriction
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Ringers Lactate / Saline Solution is given for volume replacement until blood is available Administer Blood Massive transfusion have a cooling effect that can cause cardiac irritability and arrest, blood should be warmed! NOTE: Presence / absence of pulses in fractured extremity
NEUROLOGIC Assess level of responsiveness, pupil size and reactivity, motor power and reflexes Determine a Glasgow Coma Scale as a baseline If signs of ICP exist o ICP monitoring may be instituted
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Classifications of Shock
1. Hypovolemic Shock Occurs when a significant amount of fluid is lost from the intravascular spaces This fluid may be blood, plasma or electrolytes solutions May result from hemorrhage, burns, GI loses or fluid shifts Cardiogenic Shock Occurs when the heart fails as a pump Primary causes of this failure are; MI, seizures, cardiac dysrhythmias and myocardial depression Secondary causes include; Mechanical resistance of cardiac function / venous obstruction Cardiac tamponade Vena cava obstruction Tension pneumothorax Distributive Shock Septic Shock Occurs as the result of bacterial and or toxins circulating in the blood The primary cause is the vasoconstrictive mediators released by gram negative bacteria affecting almost every physiology system Any septic focus has the potential to produce septic shock Anaphylactic Shock A severe, whole body allergic reaction After being exposed to a substance like bee sting venom, the persons immune system becomes sensitized to that allergen On a later exposure, an allergic reaction may occur, this reaction is sudden, severe and involves the whole body Anaphylactic Shock can occur in response to any allergen Neurogenic Shock Sometimes called vasogenic shock, results from the disruption of the Autonomic Nervous Systems (ANS) control over vasoconstriction The veins and arteries immediately dilate, drastically expanding the volume of the circulatory system with a corresponding reduction of blood pressure Other classifications of shock Spinal Shock Insulin Shock
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Subsequent Assessment
Initiate immediate intervention as indicated Resuscitate as necessary Administer O2 Start cardiac monitoring Control hemorrhage Assess Level of Consciousness Important indicator of shock because it reflects cerebral perfusion Change may include Confusion Irritability Anxiety
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Agitation Inability to concentrate Watch for increasing lethargy progressing to obtundation and coma, indicates progression of SHOCK Monitor arterial Blood Pressure Fall in the systolic pressure o There is no absolute value in a blood pressure that indicates a stroke state o It is the deviation from normal that is important o A systolic pressure below 80 mm Hg or a mean arterial pressure below 60 mm Hg is indicative of SHOCK Assess pulse quality and rate change o The rate usually is increased o Weak, thread pulse due to cardiac output and peripheral vascular resistance Assess Urine Output o A in renal blood flow or pressure will result in UO o Ideally, in an adult, the UO should be 30 60 mL/hr o An output of less than 25 mL/hr may indicate SHOCK Assess capillary perfusion o Pale, ashen, mottled, cold and sweating skin indicates potent vasoconstriction o Capillary refill of greater than 2 seconds indicates vasoconstriction Also assess for: o Subjective feelings of impending doom o Metabolic Acidosis due to anaerobic metabplism within cells o Excessive thirst
General Interventions
o o o Administer 100% O2 By non-rebreather face mask to maintain the partial pressure of arterial oxygen at 90 100% Assist with intubation if the patient is unable to maintain airway Fluid restriction! 2 large bore IV lines should be established Ringers Lactate is the initial fluid choice Normal Saline is the 2nd choice, because of hyperchloremic acidosis may develop if massive amounts of normal saline is infused Rate of infusion depends on severity of blood loss and clinical evidence of hypovolemia Pack Red Blood Cells (PRBCs) are infused when there is massive blood loss Additional platelet and coagulating factors are given when large amounts of blood are needed because replacement blood is deficient in clotting factors. WARM the blood Insert an indwelling urinary catheter Record UO q15- 30 minutes Urinary volume reveals adequacy of kidneys and visceral perfusion Maintain patient in supine position with the legs elevated This position is CONTRAINDICATED in patients with HEAD INJURIES ECG Monitoring Dysrhythmias may contribute to shock Maintain ongoing nursing survey of total patient reaction to treatment VS Hct and Hmg Color Coagulation CVP Electrolytes ABGs UO Nursing ALERT! ECG Trendelenburg position is no Immobilize fracture to minimize blood loss longer recommended because of Maintain normothermia the potential for risking Too much heat produces vasodilation, it compromise because of pressure can fluid loss through perspiration on abdominal organs
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A patient who is in septic shock should be kept COOL because temperature increases the cellular metabolism effects of shock
Pharmacologic Interventions
Vasopressin may be necessary but not until volume is Antibiotics Broad spectrum for septic shock
Primary Assessment
Assess Airway, Breathing and Circulation Check for Level of Consciousness
Nursing ALERT!
When the diagnosis of heat stroke is made or suspected, it is imperative to reduce patient temperature!
Risk Factors
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Advanced age Strenuous exercise in heat Medications such as Anticholinergics that interfere with perspiration
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Subsequent Assessment
1. 2. 3. Hot, dry, flushed skin progressing to pallor in late circulatory collapse Elevation of body temperature above 105 F (40 C) CNS disturbances include: Tremors, seizure, fixed and dilated pupils
Risk Factors
Exposure to cold Submersion in cold water Age (Elderly and very young)
Assessment
Locate signs and symptoms Pallor Paresthesia Pain to absence of sensation of involved body part Systemic Signs and Symptoms Core temperature < 94 F (34.4 C) Weak and irregular pulse Level of consciousness
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Continually assess cardiac status ABGs Electrolytes Glucose BUN Start appropriate IV line: PNSS DO NOT GIVE RINGERS LACTATE o Cold liver may not be able to metabolize the Lactate Rewarming Techniques: To prevent cardio collapse Passive External Rewarming (Temperature above 82.4 F or 28 C) o Remove all wet / cold clothes and replace with warm clothing o Provide insulation by wrapping the patient in several blankets o Provide warm fluid to drink o Disadvantage: Slow process Active External Rewarming (Temperature above 82.4 F) o Provide external heat for the patient warm hot water Do not apply hot water bottles directly to the skin o Warm water immersion o Disadvantage: Causes peripheral vasodilation returning cool blood to the core causing an initial lowering of the core temperature Active Core Rewarming (Temperature below 82.4 F) o Inhalation of warm, humidified oxygen by mask / ventilator o Warmed IVF and gastric lavage / warmed standardized dialysis solution
Frostbite
Definition: A trauma due to exposure to freezing temperature that cause actual freezing of tissue fluids in the cell and intracellular spaces, resulting in vascular damage
Nursing ALERT!
Extreme caution should be maintained when transporting hypothermia patients since the heart is near fibrillation threshold
Subsequent Assessment
Types of Frost Bite Frost Snip o Initial response to cold (Gradual onset) o Signs and Symptoms: Skin appears white; body parts: numb and pain free Superficial Frost Bite o White and waxy skin o Palpation: Stiff skin with pliable sift and normal bounce of underlying tissue o Sensation is absent Deep Frost Bite o White, yellow-white or mottled blue-white skin o Palpation: Both the surface and underlying tissue is frozen o The affected part has no sensation
Nursing ALERT!
Treatment and Nursing Care
1. 2. Frost Snip Place the warm hand over the affected area Superficial Frost Bite Handle the part gently and remove all materials that may impede circulation Deep Frost Bite Definite rewarming should be continuous until it is complete Refreezing of partially thawed area reverses ice crystal formation In tissue that may cause further tissue damage
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Rewarming with tepid water 98.6 F and 104 F (37 40 C). The rewarming procedure may take 20 30 minutes Protect the thawed part from infection Place sterile gauze / cotton between affected finger / toes Elevate the part to help control swelling Use a foot cradle to prevent contact with bleeding Provide appropriate electrolyte Pharmacologic Intervention Opioids pain control Antibiotic if there is an open wound Tetanus Prophylaxis
Patient Education
Reinforce NO SMOKING POLICY because of the vasoconstricting effects of nicotine which further reduce the already deficient blood supply to injured tissue Elevate the part to help Use a foot cradle
Behavioral Emergency
Violent Patient
Assessment o Overacting o Aggression o Anger out of proportion to the circumstance Determine Risk Factors for Violence Intoxication with drugs / alcohol Acute paranoid psychosis, paranoia / borderline personality
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Use restraints but with minimal force Have a specific plan and well trained personnel available when applying restraints. If patient is intoxicated, restraint in a left lateral position and monitor closely for aspiration Use emphatic and supportive verbal interactions while applying restraints Check circulation of restrained extremities
Depression
Disorder of mood / affect characterized by feelings of depression, sadness and hopelessness
Assessment
Signs and Symptoms Sadness Apathy Feelings of worthlessness Self blame Suicidal thoughts Desire to escape Worsening of a mood in morning Anorexia Weight loss and sleeplessness
Suicidal Ideation
Is a common medical term for thoughts about suicide which may be as detailed as a formulated plan without the suicidal act itself
Assessment
Assess for psychiatric risk factors Associated psychiatric diseases (e.g. substance abuse, affective disorders) Personality traits such as aggression, impulsivity, depression and hopelessness Persons who have early loss, social loss Genetic and familial factors: family history of suicide, certain alcoholism and alcoholic abuse Determine whether patient has committed suicidal intent, such as talking of someone elses suicide Determine if patient has suicidal attempts. This type of patient has greater potential risk Ask if there is a specific plan for suicide and means to carry out the suicide
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Assessment
Patient received and treated in the Emergency Department may affect the psychological well-being of the patient in the future Call the rape council intervention center DO NOT LEAVE the PATIENT ALONE and accept emotional reactions of the patient Emotional trauma may be present for weeks, months, and years Rape Trauma Syndrome The reaction of the patient towards the incident Phases of Rape Trauma Syndrome: (Acute Phase, Denial Phase, Reorganization Phase) 1. Acute Phase Other term is Disorganization Phase Patient is in the state of: 1. Shock 2. Disbelief 3. Fear 4. Anxiety 5. Guild 6. Humiliation 7. Suppression of feelings My last for months to years 2. Denial Phase Unwillingness to talk about the incident Anxiety and fear Patient experiences 1. Flashbacks 2. Sleep disturbances 3. Hyperalertness 3. Reorganization Phase Putting incident into perspective Signs and Symptoms: 1. Sexual fears 2. Phobias Interview the patient Consent should be obtained before examination Most Emergency Departments have prepared rape evidence collection kit Written protocols for treatment of injuries Legal documents, STDs and pregnancy prevention Remember that the evidence collection kit is meant to preserve for forensic evidence Verbatim transcription of patient history Ask the patient if: o Douched o Bathed o Gargled / Brushed teeth o Changed clothes
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o Urinated / Defecated since the incident This may alter interpretation of subsequent findings Record Time of admission Examination date Time of sexual assault General appearance of the patient Document evidences of trauma Bruises Lacerations Secretions Torn bloody clothing (Body diagram) Describe the emotional state of the patient
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Conduct pregnancy test Label all specimen Name of patient Date and Time of collection Body area from which specimen were obtained Names of personnel collecting the specimen Give the specimen to the crime laboratory Obtain an itemized receipt Photographs should be taken by authorized persons ONLY Other interventions: Treat physical trauma Protect patient from STD Give antibiotic prophylaxis for 7 days o Ceftriaxone o Tetracycline o Zithromax Protect patient against pregnancy Determine if pregnancy existed before the attack Negative pregnancy test should be obtained before giving post coital contraceptives (e.g. Estradiol) Hormonal Treatment o To prevent pregnancy Morning Pills Allay fear for HIV by considering prophylactic treatment Offer cleansing facilities o Douching o Showering o Mouth wash Follow-Up Interventions Make a follow-up appointment o Except for patients who have Syphilis o 6 weeks later Inform patient that counseling services are available both to the patient and the family Encourage patients to resume previous functions unless contraindicated Patient should be accompanied by a friend / family when leaving the hospital
Signs of Bioterrorism
1. 2. 3. 4. 5. 6. Large number of people with similar disease Cases of unexplained illness More severe illness expected for a specific pathogen Illness resistance to treatment Unusual occurrence of disease A single case f unusual disease
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Assessment
Signs and symptoms: Fever Cough Widened mediastinum on chest X-rays
Small Pox
Transmission Inhaled / direct contact with variola virus 2 weeks incubation period
Assessment
Signs and Symptoms Rash developing then turns to a blister after 3 days through the face, then to the trunk, high fever, fatigue
Botulism
Transmission Ingestion of contaminated food infected with Clostridium botulinum
Assessment
Slurred speech N/V Diarrhea Descending muscle weakness
Toxicologic Emergencies
The goals of Toxicologic emergencies are the following: 1. Supportive 2. To prevent / minimize absorption and promote excretion 3. TO provide an antidote
Primary Assessment
Assess for Airway, Breathing and Circulation
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Maintain an open airway Some substances may cause soft tissue swelling of the airway
Primary Assessment
Identify the poison / brief history taking Monitor neurologic and fluid and electrolyte status Diagnosis: Blood and urine test, serious cases gastric contents can be submitted for evaluation
Food Poisoning
Sudden explosive illness which may occur after ingestion of food / drink that is contaminated Identify the amount and type of food If possible, bring the food / gastric contents / vomitus / serum or feces to the health care center for further evaluation Assess fluid and electrolyte balance
Assessment: Identify the substance if it is basic / acidic Note the amount of substance induced Assess for clinical manifestations: Signs and Symptoms
Burning sensation where the substance was taken Dysphagia Due to injuries to tissues Vomiting
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NON CORROSIVE POISONING Secondary intake of substances such as chalk / watusi Assessment Identify the substance induced Treatment and Nursing Care Induce vomiting if the nurse is certain that it is non-corrosive Bring the container of the induced substances Dilute the chemical substances with 3 4 glasses of milk / water Carry out NGT plus gastric lavage Induce vomiting using the syrup of ipecac, Heimlich Maneuver and gag reflex stimulation
Assessment
Risk Factors: Environmental exposure (Length) Underlying disease such as anemia Respiratory and cardiovascular problems that may aggravate the patients condition Assess adventitious sounds such as: Stridor = May indicate poisoning is caused by smoke inhalation, rales / wheezes Assess LOC Pink, cherry-red /cyanotic pale skin Diagnostics: ABGs
GOAL: a) Reverse cerebral and myocardial hypoxia b) Hasted carbon monoxide elimination
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o Drug of Choice: EPINEPHRINE o Administer bronchodilators to help relieve the bronchospasm o IVF of Choice: Lactated Ringers Subsequent Assessment: o Obtain history of insect stings, previous exposure and allergies o Inspect skin for local reactions (Erythema, pain and edema on site of injury) o Continue to monitor BP and respiratory status General Interventions and Nursing Care o Apply ice packs to relieve pain o Elevate extremity with large edematous local reactions o Clean the wound thoroughly with soap and water / anti-septic solution Pharmacologic Intervention: Oral antihistamine for local reactions o Administer Tetanus prophylaxis if not to date Health Education: o When sting occurs, take EPINEPHRINE IMMEDIATELY o Do not squeeze venom sac because this may cause additional venom to be injected o Report immediately to the nearest health facility Snake Bites Primary Assessment and Intervention o Assess Airway, Breathing and Circulation if patient is not alert o Observe for neurotoxicity accompanied by respiratory paralysis, shock, coma, death during severe envenomation o Be prepared to do CPR Subsequent Assessment o Locate bites to the head and trunk may progress more rapidly o Assess for local reactions: Burning pain, swelling and numbness o WOF Systemic reactions including: Nausea, sweating, weakness, paralysis, signs of shock and coma General Interventions o Keep the patient calm and rest in recumbent position with the affected extremities o Administer O2 o IVF of Choice: Lactated Ringers o Monitor for bleeding o Administer blood products for coagulopathy o Pharmacologic Treatment: 1. Antivenin and be alert to allergic reactions 2. Vasopressor for shock treatment
Treatment
Immediately expose the skin with running water \ Please keep in mind the safety of the health care provider attending to the patient Standard Burn Treatment: Debridement and plastic surgery (Chronic Burn) Administration of prophylactic medications Schedule a follow-up check up / refer to a Dermatologist for further evaluation
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Naloxone HCl (Narcan) Identify the amount and type of drug Conduct history taking: Supportive, realistic and emphatic
Subsequent Assessment
Perform Physical Examination If the patient is unconscious, consider all the possible causes of loss of consciousness and monitor levels of level of consciousness Monitor VS Monitor pupils for extreme miosis (pinpoint pupils) which may indicate narcotic overdose Look for needle marks and external evidences of trauma Perform a rapid neurologic assessment: LOC, pupil size, and reactivity and reflexes Examine the patients breath for characteristic odor of alcohol and acetone Keep in mind that many drug abusers take multiple drugs simultaneously Try to obtain history from the patients
General Interventions
Goal: A. Support the respiratory and cardio function B. Give definite treatment for drug overdose C. Prevent further absorption, enhance drug elimination and reduce its toxicity Stabilize ABC Airway: Insert Endotracheal Tube Breathing: Respiratory rate, ventilatory-ambu-bag Circulation: CVP line, ECG, Pulse Rate Remove drug from stomach immediately if the patient is conscious, IF unconscious, perform Gastric Lavage In patients lacking gag reflex or cough / cough reflex, perform this procedure only after intubation with cuffed endotracheal tube to prevent aspiration of gastric contents Provide comfort measures If hypothermia / hyperthermia IVF of Choice, if there is Hypotension: PNSS Treat seizure with Diazepam (Valium) and promote seizure precaution
Laboratory: Urinalysis
Provide psychiatric precaution measures to the patient / refer to psychotherapy. Consult if necessary When the patients physiologic status is abnormal, refer to the rehabilitation program
SPECIFIC DRUGS:
1. 2. 3. 4. 5. CNS Stimulants Hallucinogens Opioids Sedatives Alcohol Abuse
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