Emergnecy Nursing part I

• rapid stabilization....plan within 1 hr
• prevention of complications
• early recovery

• rapid assessment
• management of emergencies
• broad knowledge base...acls/pals etc...
• crisis intervention
• good communication skills
• triage abilities....decide if emergent/non emergent
• good at patient teaching....filling in Dr. gaps

implied consent is used....and transfusion occurs

• trauma intervention program services
• 24/7 volunteer group that helps with crisis intervention

• no dr. visit in last 20 days of life
• dr. cant figure out reasonable cause of death
• possible/known homicide/suicide
• possible criminal action
• when aspiration, starvation, drugs, alcohol, poisoning are suspected as cause of death
• when contagious disease is known or suspected cause
• death while in custody/prison
• all deaths of state hospital patients
• SIDS
• death from surgery

it is a sorting of patients

process of deciding the priorities for intervention of a given person or groups of people based on their acuity/needs

• allows for early assessment of the seriously compromised patient
• allows for immediate intervention in life threatening situations
• decreases anxiety/fear
• expedition of non critical patients

• emergent
• urgent
• non-emergent

need immediate medical attention, time and delay could be life threatening

• stroke
• MI
• anaphylaxis
• severed limb
• airway compromise
• SCI
• seizures
• Diabetic complications
• severe shock
• obvious multiple trauma
• excessively high temp-over 105
• emergency childbirth, complication of prego,
• hemorrhage
• eclampsia

person needing medical attention within the next few hours

• dehydration
• concussion
• burns
• fx
• chest pain from URI
• severe pain
• temp 102-105
• drug overuse
• poisoning

a condition that does not require the resources of an ED or emergency service, non acute or minor in severity

• dead already
• laceration
• fx/sprains/strains
• frequent flyers
• chronic backache/headache

anyone who according to my instinct looks sick, seems sick or acts sick should be triaged at my discretion, regardless of the "rules"

• MV over 35 mph (possible ruptured aorta)
• forces of decal as in falls or explosions
• loss of consciousness after an accident
• chest/abdominal pain after injury
• fx of 1st or second ribs...high mortality
• fx of 9,10,11th ribs or more than 3 ribs
• possible aspiration
• possible lung tissue contusions
• possible cervical spine trauma in pt. w/head injury
• pulse rate >120 at rest

1st or 2nd

• Airway
• Breathing
• Circulation
• Disability
• Exposure/Environmental control

*this assessment is mandatory for all patients no matter their chief complaint*

• clear and open
• assess for obstruction....tongue
• assess for respiratory distress
• check for loose teeth or foreign objects
• assess for bleeding, vomit or edema

• suction
• jaw thrust maneuver
• ET tube
• rigid cervical collar, backboard, towel rolls, forehead secure to backboard

• paradoxical movement
• accessory/abdominal muscle involvement
• listen/feel for air being expired
• RR?
• note nail beds, mucous membrane and skin for cyanosis
• assess for JVD
• assess position of trachea

• supplemental O2
• AMBU with 100% O2 if resp inadequate
• prepare for intubation
• suction
• prepare for chest tube insertion

• carotid/femoral pulse
• palpate pulse for quality and rate
• assess color, temp and moisture of skin
• check cap refill
• blood pressure

• CPR if pulse absent
• shock=2 lg bore IV, NS or LR
• blood products admin
• auto transfusion if isolated chest trauma
• blood samples for type and cross....control bleeding

brief neuro assessment-LOC/pupils

Identify deformities-inspect extremities for any obvious deformities and determine ROM and strength

pain assessment

• periodically reassess LOC and mental status
• immobilize any obvious deformity
• periodically reassess pain

• Full set of VS/family present
• Give comfort measures
• History and Head to toe assessment
• Inspect posterior surfaces

• Allergies
• Medications
• PMH
• Last meal
• Events preceding event

>90....preferably 100+

• looking for CSF or blood
• otoscope look at tympanic membrane, should reflect light...NOT blue (blood behind membrane)
• Battle sign

• look for orbital ecchymosis
• conjunctival redness
• rhinorrhea
• PERRLA
• Cardinal gaze
• push bone for orbital fx

• check for missing teeth
• bleeding points
• bleeding/edematous tongue
• abscess?

increased volume w/distention is seen with patient in supine or semi fowlers position

• from....
• tension pneumothorax
• lateral displacement of heart
• myocardial tamponade
• myocardial contusion
• JVD

check for stability of the chest and rib cage with BOTH a sternal press and barrel push against sides of the ribs toward the center

subcutaneous emphysema felt in the neck and subclavicular areas

check for quality, rate, equality and adventitious or diminished breath sounds

• check for discoloration, marks, wounds, swelling
• carefully logroll to examine the back looking for retroperitoneal bleeding, and exit wounds

**ausculatate 1st, then palpate looking for guarding and distention

RUQ

RLQ with rebound

press downward on both hips and the symphisis, even a semiconscious patient will groan if they have a broken pubis

a lot of occult bleeding

• confirm prego with HCG
• do type and cross
• find out Rh factor
• US to see if fetus if viable
• ask for hx of previous prego

• check for pain
• deformity
• ROM
• look for cellulitis
• abscesses

strip em and flip em

• check for bleeding
• c spine...in line
• bruising
• lacerations
• place paper clips at site of GSW

remove all of their clothes

• altered state of mentation
• abnormal respiratory pattern
• abnormal eye signs
• abnormal body movements, reflexes, posture
• inappropriate response to painful stimulation

we are all entitled to have 1 seizure....but with the 2nd you will go on meds

assessment for unconscious patient

• Alcohol
• Epilepsy/encephalopathy
• Insulin
• Overdose
• Uremia

assessment for unconscious patient

• Trauma/Tumor
• Infection-sepsis
• Psychiatric-schizo/bipolar
• Stroke/Syncope/Shock

• Secure the airway and establish IV access
• Glasgow coma scale with brief neuro exam
• Obtain blood samples BEFORE any meds are given
• O2
• ABG
• Monitor ICP
• Foley
• Control body temp

IV of NS to get the glucose back in to the cell 1st....and then give insulin plus Dextrose

their bodies work differently....so always limit fluids you give

45+ yo

• want the patient to be stable within the first hour
• controlled airway
• aggressive management of shock
• appropriate definitive care

• think worst first
• don't panic
• use a systematic approach to evaluate and treat
• look beyond the obvious
• be aggressive with your management

• get info from anyone...pt, paramedics, family
• stripe em and flip em
• mech of injury
• who did it and how
• any known drugs on board
• any allergies
• any medical problems
• alcoholic withdrawl or dts possible
• time and amount of food/fluids
• date of last tetanus/booster
• bleeder? on anticoagulants?

get an accurate weight

• type of vehicle and speed at impact
• circumstances on impact-stationary, moving
• thrown from vehicle?
• direction of forces...head on, read end?
• wearing aseatbelt

with the impact and the shearing forces of deceleration

possible tissue trauma on lower abdomen or retroperitoneal injury

steering wheel trauma with possible facial bone damage and airway compromise, damage to sternal area, fx ribs, possible cardiac contusion or tamponade

thrown into or through the windshield.

evaluate for facial trauma and airway compromise

fractured femur

fracture to the head of the femur

• were they wearing a helmet?
• speed at impact
• were they thrown?

• head injuries with facial lacerations
• neck and c spine injuries
• fracture femurs

• impalements
• GSW
• knives
• icepicks

always look for entrance and exit wounds....can do this unless you remove all of their clothes

• men thrust upwards
• women use overhand movement and thrust downward

leave the object in place and stabilized until surgical removal is accomplished...could be tamponading a slashed artery

• type and cross
• ancef for infection
• pain meds

• cause...slipped/syncope/jump
• distance of fall
• surface of landing
• position of landing...on feet, head, supine

• compression fx of the spine from forward flexion
• fx of heels, knees, hips
• deceleration injury to the liver, spleen and laceration of aorta distal to the left subclavian artery

• muffled, distant heart sounds
• hypotensive
• neck vein distention
• increased CVP

medical emergency-pericardiocentsis with surgical repair

• dyspnea
• decreased chest wall movement
• diminished/absent breath sounds
• hyperresonance to percussion

chest tube insertion with drainage at 3/4 mid intercostal or 5/6 .....????

• dyspnea
• diminished or absent breath sounds
• dullness to percussion

chest tube insertion with drainage plus autotransfusion of collected blood and treatment for hypovolemia as needed

• cyanosis
• air hunger
• violent agitation
• tracheal deviation AWAY from affected side
• subcutaneous emphysema
• neck vein distention

needle decompression and chest tube insertion

fracture of 3 or more adjacent ribs causing loss of chest wall stability

• paradoxic movement of chest wall
• respiratory distress
• associated hemothorax, pneumothorax or pulmonary contusion

• stabilize flail segment with intubation or taping
• oxygen
• analgesia

pain

pain management...splint is NOT acceptable

• guarding/splinting of abdominal wall
• hard, distended abdomen
• decreased/absent bowel sounds
• contusions, abrasions, bruising over the abdomen
• pain, rebound tenderness
• hematemisis
• avoiding of abdominal breathing

• control external bleeding with direct pressure
• IV access
• blood type and cross/CBC
• stabilize impaled object with bulky dressing
• cover protruding organs or tissue with sterile saline dressing
• insert catheter
• obtain urine for UA
• Insert NG if no facial trauma
• anticipate diagnostic peritoneal lavage

• VS, LOC, O2 saturation and UO
• keep warm with blankets, warm IV fluids or warm humidified O2
• Look for Grey Turner/Cullens
• Kehrs sign....left shoulder pain
• Lap belt injuries
• signs of shock

• increased WBC >15,000
• Increased amylase and liver enzymes
• hematuria
• blood in stool or NG aspirate
• **falling H/H

• infection
• compartment syndrome
• venous thrombosis
• fat embolism
• Disseminated intravascular coagulation (DIC)

• 5 P's
• pain
• pressure
• paresthesia....late
• pallor....late
• pulseless....late

• prevention is the key
• avoid elevation of the extremity above the heart
• avoid cold compress
• loosen the badage or bivalve the cast
• fasciotomy
• monitor for signs of infection

• unilateral leg edema/swelling
• extremity pain
• warm skin
• erythema
• systemic temp >100.4

• prevent
• antiembolism hose
• sequentials
• hourly dorsiflex/plantarflex toes
• warfarin/heparin

long bone fx

• chest pain
• tachypnea
• cyanosis
• dyspnea
• apprehension
• brady
• decreased O2 sat
• petechiae around the neck, anterior chest wall, axilla, buccal membrane and conjunctiva of the eye

• prevention is key
• immobilize long bone fx
• limit repositioning until fx is stabilized

clotting and bleeding at the same time

• follows severe trauma
• unexplained drop in BP
• petechiae and ecchymosis
• bleeding from at least 3 points at once

• early intervention is key with anticipation of
• rapid shock
• ADMIN HEPARIN
• O2
• Maintenance of BP
• vigorous treatment of infection or bleeding

• single lead rhythm strip
• H/H
• type and cross
• CBC
• Chem 7
• Drug screen if necessary
• ABG's
• Cardiac enzymes
• EKG
• Serum lypase
• Liver enzymes
• IVP, cystogram, CXR, C spine, CT
• UA for presence of heme
• Culture and sensitivity

HYPOTENSION

airway issue...check it again to ensure the patient is ventilating adequately with enough O2

possible blood loss and incipient shock

can also mean they are in pain or have a fever

decreased cerebral blood flow and incipient shock

can also mean the person may have an infection or alcohol/drugs on board

release of epi when the person is in shock

• severe chest damage
• tension pneumothorax
• cardiac tamponade
• CHF

hypovolemia

decreased UO...cuz it is the major monitor of visceral blood flow

• they are stable
• not hypoxic
• no cervical spine fx
• no aortic tear
• no pneumothorax/hemothorax
• no esophageal or bronchial trauma

calming techniques and figure out the problem....don't just give them ativan