CEN review class

when baby and placenta have been delivered

• *written consent
• *documented risks/benefits
• *must send records/results
• *document name/address of any on-call
•   physician who refuses or fails to appear
•   in reasonable time
• *direct communication between transferring
•  and receiving providers
• *receiving must have available beds
• *document receiving physician and phone #
• *experienced staff/equipment during transfer

airway

basic airway meneuvers and adjuncts

airway assessment and C-spine stabilization are always combined in trauma

tip of mouth to angle of jaw or tip of earlobe

tip of nose to angle of jaw

midface trauma

6.5/8.0

(16 + age in years) / 4

may rapidly deteriorate

2nd intercostal space at mid-clavicular line

90-120

similar to adults

100-160

closure of AV valves at beginning of systole

• closure of semilunar valves at beginning of
• diastole

heart failure, fluid overload

ventricular hypertrophy

• mitral regurgitation
• aortic stenosis

• mitral stenosis
• aortic regurgitation

protect airway

• pulmonary edema
• ruptured diaphragm
• LV dysfunction
• pregnancy
• abdominal evisceration

lying flat at least 5 min

HR & BP at 1 & 3 min after position changes

• SBP drop >/= 20
• DBP drop >/= 10
• HR increase >/= 20

at least 6 months

• emergent
• urgent
• non-urgent

• life-threatening
• emergent
• urgent
• non-urgent

• 1 resuscitation- seen immediately
• 2 emergent/very urgent - seen in 10 min
• 3 urgent seen within 30 min
• 4 semi-less urgent - seen in 60 min
• 5 non-urgent seen in 120 min

5 tiered system

not recommended

• 1 ID problem
• 2 Review research/data that addresses
•    the question
• 3 evaluate findings for validity, relevance,
•    and applicability
• 4 integrate the new info into practice
• 5 Evaluate changes in practice for sesired outcome

• Never let family leave before patient
• give map and phone number

no, should be obtained after MSE

life or limb threatening situation

• provider must:
• 1. describe procedure
• 2. explain alternatives
• 3. detail risks

action or inaction that does not meet standards of care and results in injury to pt

• 1. duty to act (relationship established)
• 2. breach of duty/contract (bad care)
• 3. proximate cause (breech was cause of
•     injury)
• 4. result in damage (injury caused by 
•     negligence)

attempt or threat to touch another person or the person's possessions without his/her consent

• actual contact with a person or the person's possessions without consent
• "unauthorized touching"

• 1. gunshot & stab wounds (self-inflicted also)
• 2. anything r/t violence
• 3. communicable diseases
• 4. child/elder/spouse abuse
• 5. death within 48 hrs admission to hospital
• 6. poisonings
• 7. fetal deaths
• 8. animal bites

only draw blood with pt express consent

may draw without pt consent with search and seizure warrant but cannot use physical force

confidential:  only those involved and debriefing team present

inquiries about marital status, sexual orientation, religion, age, children

OSHA

technical tasks

steps of nursing gprocess, triage, assessment, patient teaching, discharge instructions

maintain chain of custody and minimize contact

document behaviors and use quotations

• 1. minimal handling
• 2. paper bag each item
• 3. don't cut thru holes or marks in clothing
• 4. hands:  don't wash, consider bagging
•     in paper bags
• 5. delay cleaning patient & wounds when
•     possible

JCAHO and CMS

• skin breakdown
• strangulation
• respiratory depression

consciousness depressed but pt maintains own airway and protective reflexes and ability to respond to stimuli

naloxone/flumazenil

need consent for BOTH sedation and procedure

monitor patient throughout procedure and recovery and not assist with procedure

• cognitive
• info about disease process, discharge instructions

• affective
• educating to change health behaviors, importance of immunizations

• psychomotor
• crutch walking, use of peak flow meter and inhalers

identify implied and expressed learning needs of the patient or learner

demonstration

• use a designated recorder
• chronicle events
• critical pt need evidence of frequent, serial assessment and interventions to help ID trends

focus on variances from normal assessment

usually develops suddenly and unexpectedly

requires immediate coordinated and effective responses by multiple gov agencies and private organizations

sudden & massive disproportion b/t hostile elements of any kind and survival resources which can be brought into action in shortest possible time

• 1. warning: impending danger
• 2. impact: disaster occurs
• 3. isolation: time from impact until outside 
•     help arrives.  Utilize available resources
• 4. Rescue: assistance from outside sources
•     arrives, continuous reassessment of event
• 5. Restoration:  days to years, slowly scale
•     down response
• 6. Normal Operations:  all functions return
•     to baseline

• multiple casualty:  100 or less casualties
• mass casualty: >100 casualties

• Red = immediate/emergent:  life-threatening
• injury, airway compromise, etc

Yellow = Delayed/urgent:  major illness/injury, requires Tx within the hour

Green = Minor/nonurgent - walking wounded, can self-treat, can wait several hours

Black = deceased/expectant - dead or expected to die:  full arrest, massive full thickness burns, fatal injureis

• sort
• assess
• lifesaving interventions
• treatment/transport

each incident will require specific chain of command

establish command center

each hospital must list chain of command and each person's duties

hospital must have disaster call tree system in place

have drills

danger zone, restricted access

requires proper PPE, basic ABC management only and antidote

control zone:  active decontamination

only emergent Tx provided, requires proper PPE

safe zone: Tx area

staging area, only need standard precautions

generalized inadequate tissue perfusion resulting in widespread impairment of cellular metabolism and dysfunction of critical organs

stimulation of SNS to release catecholamines which stimulate beta and alpha receptors

Decreased renal BF activates renin-angiotensin aldosterone system

Reduced capillary hydrostatic pressure

Clinical manifestation:  anxiety, hyperventilation, narrowing pulse pressure with normal BP, cool clammy skin, increasing serum glucose

increased BP, HR, myocardial contractility, and BF to lungs

release of glucocorticoids

vasoconstriction

aldosterone - increases sodium and water reabsorption

inceased secretion of ADH causes water retention

• Alpha:  arteries
• Beta 1:  heart
• Beta 2:  lungs

translocation of fluid from interstitial space to intravascular space

increases circulating blood volume

may appear relatively normal

• anxiety
• hyperventilation
• narrowing pulse pressure with normal BP
• cool clammy skin
• increasing serum glucose

• 1. vessels begin to vasodilate
• 2. organ dysfunction
• 3 anaerobic metabolism
• 4.histamine release

decreased peripheral resistance and BP

decreased venous return to the heart (preload)

decreased liver function and production of clotting factors

release of myocardial depressant factor (MDF) resulting in further depression of cardiac function

decreased production of surfactant

decreased GFR and ability to clear toxins

cell hypoxia, acidosis (lactic and metabolic)

capillary permeability increased

fluid shift from intravascular to interstitial space

• alterations in LOC
• hypotension
• significant tachycardia
• peripheral cyanosis
• decreasing UO
• decreased pulmonary capillary BF and gas exchange
• microcapillary clotting from sluggish BF

endothelial damage to lungs resulting in metabolic and respiratory acidosis

• 1. progressive organ dysfunction leading
•     to death
• 2. acidosis
• 3. clotting derengements
• 4. cerebral ischemia

• 1. cold, pale, mottled skin
• 2. extremely weak, thread pulses
• 3. significant tachycardia & dysrhythmias
•     deteriorating to bradycardia
• 4. severe hypotension
• 5. hypothermia

alteration in circulating volume:  preload

loss of blood, plasma, or other body fluids

• 1. massive blood loss
• 2. vomiting/diarrhea
• 3. diabetes insipidus
• 4. burns
• 5. DKA
• 6. excessive diaphoresis

• up to 15% loss/750mL in adults
• HR <100, BP normal
• essentially normal physical exam

15-30%/750-1500mL in adults

HR >100, BP normal, decreased pulse pressure

pale, anxious, diaphoretic, cool/clammy skin

30-40%, 1500-2000mL for adults

HR>120, hypotensive, decreased pulse pressure

very anxious, confused, oliguria

>40%, >2000mL in adults

HR>140, hypotension, decreased pulse pressure

lethargic, unresponsive, anuria, cold, pale

• distal femur
• proximal tibia
• proximal humerus (preferred in adults)
• sternum (requires special device)

• last option
• should be placed once stabilized and via sterile technique unless no other option

3:1 crystalloid to blood

1:1 colloid to blood

patients with temp <34 C have 50% higher mortality rate

• 20mL/kg bolus (X2-3) crystalloid
• 10mL/kg PRBC or colloids

impairment of pumping ability/contractility of heart

• 1. MI - most common
• 2. myocardial contusion
• 3. cardiomyopathies
• 4. valve dysfunction
• 5. ruptured septum

obstruction of forward flow of blood- obstruction causes decreased circulating volume by preventing myocardium from mechanically emptying or filling during diastole

• 1. tension pneumo
• 2. pericardial tamponade
• 3. pulmonary embolism
• 4. aortic aneurysm

• 1. restlessness, apprehensive, confused, obtunded
• 2. chest pain
• 3. pale, cool, clammy skin
• 4. thread peripheral pulses
• 5. delayed cap refill
• 6. EKG changes/dysrhythmias
• 7. shallow, rapid breathing
• 8. decreased UO
• 9. metabolic acidosis
• 10. hypoxemia/hypocapnia
• 11. weak or muffled heart sounds, S3 gallop
• 12. distended neck veins (RV failure)

• 1. ABC's
• 2. EKG
• 3. anticipate need for thrombolytics
• 4. manage preload
• 5. improve contractility
• 6. decrease afterload
• 7. anticipate need for IABP
• 8. correct obstruction:  needles thorocostomy, pericardiocentesis

increase:  more volume

decrease:  nitroglycerin, furosemide, morphine

inotropes: dobutamine, milrinone

stimulates Beta 1 receptors:  increased cardiac contractility

• nitroprusside/nipride
• ACE inhibitors

abnormal placement of intravascular volume

• 1. septic shock
• 2. anaphylactic shock
• 3. neurogenic shock

toxins released by invading organisms cause vasodilation and activate cellular, humoral, and immunologic systems

massive vasodilation and inceased capillary permeability

• gram pos - exotoxins
• gram neg - endotoxins

nonspecific inflammatory response to a variety of stimuli

• Must have 2:
• 1. temp <36C or >38C
• 2. HR >90
• 3. tachypnea >20 or PaCO2 <32
• 4. WBC <4000 or >12,000 or >10% band formation

SIRS + infection or presumed infection

Sepsis with >/= 1 organ dysfunction

sepsis + hypotension that requires vasopressors (refractory to crystalloids)

involving at least 2 vital organ systems:  respiratory, cardiac, nervous, renal, hepatic

• 1. tachycardia
• 2. increased CO/index
• 3. decreased vascular resistance
• 4. widened pulse pressure
• 5. normal BP or mild hypotension
• 6. flushed skin
• 7. decreased LOC

• 1. progressive decline in LOC
• 2. profound hypotension
• 3. pale, cool, clammy/mottled skin
• 4. weak, thread, peripheral pulses
• 5. severe acidosis
• 6. hypoxemia & increased work of breathing
• 7. systemic and pulmonary edema

• 1. support ABC's
• 2. volume
• 3. vasopressors
• 4. Tx infection:  ABX

• 1. sudden onset
• 2. severe allergic reaction: systemic antigen-antibody reaction, hypersensitivity
• 3. massive vasodilation and increased capillary permeability

• 1. antibiotics
• 2. shellfish
• 3. peanuts
• 4. eggs
• 5. stinging insects (hymenoptera)

• 1. anxiety, impending doom
• 2. pruritus
• 3. uricaria, rash
• 4. sudden HA, ABD pain
• 5. dyspnea, tachypnea
• 6. syncope
• 7. angioedema
• 8. skin warm & flushed (early)
• 9. skin cool & clammy (late)
• 10. stridor &/or wheezing
• 11. nasal flaring
• 12. use of accessory muscles
• 13. profound respiratory distress

• within 3 hours:
• obtain lactate
• blood cultures before antimicrobials
• broad spectrum ABX
• 30mL/kg crystalloid bolus for hypotension or lactate >4

• within 6 hours:
• vasopressor if hypotensive despite fluids (NE preferred)
• goal MAP >/= 65
• measure CVP and ScVO2
• rre-measure lactate

alpha and beta equally

alpha > beta

alpha only

dopamine, beta 1 and alpha depending in dose

• epinephrine 1:1000 (1mg/1ml) 0.1-0.5mg IM/SQ or IV in severe cases (1:10,000) 1mg/10mL
• antihistamines:  H1 blockers- Benadryl
•   H2 blockers - famotidine, ranitidine
• volume replacement
• vasopressors

• 1. loss of sympathetic vasomotor function
• 2. uncontested parasympathetic response

spinal cord injuries at or abve level of T6

brain stem injuries, spinal anesthesia, depressant and hypoxia

• 1. hypotension & BRADYCARDIA
• 2. warm, dry, flushed skin
• 3. poikilothermia - can't control temp
• 4. spinal shock - neurogenic motor dysfunction or areflexia noted below the level of the lesion

• 1. manage ABC's
• 2. volume: admin with crystalloids
• 3. maintain normothermia
• 4. vasopressors: phenylephrine, NE
• 5. stabilize spine

33%`

hyperchloremic metabolic acidosis

NS

isotonic- increases volume without altering NA+ concentration or serum osmolality

isotonic - increases volume and replces intracellular fluid losses

LR

liver dysfunction: lactate is converted in the liver

metabolic alkalosis r/t lactate converted to bicarbonate

• hypertonic - increases plasma volume with lower volumes required
• used in conjunction with conventional resuscitation fluids
• improve cerebral perfusion

help keep water in intravascular space

administer slowly

may cause fluid overload ad pulmonary edema

blood and volume replacement

increases O2 carrying capacity of blood

AB

kept frozen - must give quickly after thawing to preent deterioration of factors V and VII

increases RBC's, HgB, and Hct

increases o2 carrying capacity of blood

O+ and O-

no significant amnt of clotting factors/platelets

consider transfusion of FFP and platelets after every 4-5 units PRBC

replaces clotting factors, plasma proteins, and plasma

used for control of bleeding and replacement from blood loss

kept frozen and must be admin quickly r/t deterioration of factors V and VII

thrombocytes in plasma

control bleeding and replacement from blood loss

increases plasma volume and the plasma colloid (oncotic) pressure

olfactory - sense of smell - rarely tested

optic - visual acuity, visual fields, detection of light reflex

Oculomotor - constricts/dilates pupil, elevate upper lid, most extraoxular movements (EOMs), up, down, in

trochlear - EOMs - look down, inward

• trigeminal
• corneal reflex
• sensation of face, scalp, oral and nasal cavities (3 branches)
• chewing, jaw movement

abducens - EOMs movement of eye laterally

Facial - facial movment and expression - raise eyebrow, smile, close eyes, lip movement, show teethc, anterior taste (rarely tested)

Acoustic (vestibulocochlear) - hearing and balance

Glossopharyngeal -swallowing, gag reflex, taste on posterior tongue, sensation of the carotid bodies

• Vagus - sympathetic/parasympathetic responses (HR, BP, RR),
• thoracic and abd viscera, gag reflex, speech

spinal accessory - shoulder shrug, head turning

hypoglossal - tongue movement

doll's eyes - normal response:  while turning head rapidly side to side, the eyes move the opposite direction to where head is turned

ice water calorics:  normal response:  eyes turn slowly toward the ear in which the ice water is injected into, then rapidly turn away

allow CO2 to build up to stimulate respiratory system to determine if patients will breathe on their own

pupils, gag, cough, and corneals

MAP - ICP

1-15

60-70

extension - injury to the brainstem

hands and arm extended outward

brainstem

flexion - hands clinched and turned inward toward body

injury above midbrain

very late sign of increased intracranial pressure (ICP)

• 1. increased systolic BP (widened pulse pressure)
• 2. profound bradycardia
• 3. abnormal respiratory pattern

late sign of increased ICP resulting from shifting of brain tissue

• 1. tumors
• 2. bleeding
• 3. swelling

altered LOC, posturing, VS changes

same as other herniations and dilated pupils unilaterally or bi-laterally

same as other herniations and constricted pupils equal

• Motor Response:
• 1 - none
• 2 - abnormal extension
• 3 - abnormal flexion
• 4 - withdraw (flexion) from pain
• 5 - localizes to noxious stimuli
• 6 - obeys commands

• Eye
• 1 - none
• 2 - opens to pain
• 3 - opens to speech
• 4 - spontaneous

• verbal response
• 1 - none
• 2 - incomprehensible words or sounds
• 3 - verbalizes but inappropriate words
• 4 - confused but converses
• 5 - oriented and coverses

metabolic imbalances, diencephalic dysfunction

third cranial nerve dysfunction, anoxia

midbrain dysfunction

pontine dysfunction, opiates, miotic drugs

regular cycles of respirations that gradually increase in depth and then decrease in depth to periods of apnea

lesions deep in cerebral hemispheres, diencephalon, or basal ganglia

deep, rapid respirations

indicate lower midbrain or upper pons issues

prolonged inspiration followed by a 2-3 sec pause

pons issue

irregular, unpredictable, shallow, then deep respirations with pauses

upper medulla, lower pons issues

• 1. vomiting
• 2. HA
• 3. irritability
• 4. inconsolable
• 5. high pitched cry
• 6. fever
• 7. redness along shunt line
• 8. fluid around shunt valve

infection:  fever, warm, redness, swelling near reservoir, s/s of increased ICP

obstruction:  altered LOC, emesis (often w/o nausea), pupil changes, VS changes indicative of increased ICP

• 1. shunt series
• 2. CT or MRI
• 3. shunt tap - CSF studies

approx. age 2

9-18 months

resting position

shrill cry, irritable, loss of appetite

no organic cause

may have aura and awareness of HA coming on

throb/pulsating in nature

can last up to 7 days

constant non-pulsating pain, cervical muscle tenderness

occur in groups followed by period of remission

excruciating - burning sensation behind eyes, associated with lacrimation and rhinorrhea on affected side

organic etiology:  tumor, aneurism

• 1. aura (visual or somatosensory)
• 2. NV
• 3. photophobia/phonophobia
• 4. difficulty concentrating
• 5. visual changes

• 1. emotional events
• 2. metabolic - fever, menses
• 3. flickering lights or TV
• 4 foods
• 5. fatigue
• 6. alcohol abuse
• 7. sleep deprivation

• 1. heat (muscular)
• 2. cold (vascular)
• 3. dark room
• 4. massage
• 5. analgesics
• 6. oxygen for a cluster HA
• 7. preventative drugs:  vasoconstrictors, beta blockers, anticonvulsants

late winter and early spring

• streptococcus pneumonia
• haemophlus influenza
• Neisseria meningitides

often don't show classic signs of meningeal irritation and fever

severe hyperextension and spasticity of the head, neck, and spinal column

occurs in meningitis

• mininges PADS the brain:
• P - pia mater
• A - arachnoid layer
• D - dura mater
• S - skull/skin

• 1. illness or exposure
• 2. altered LOC
• 3. HA (occipital)
• 4. fever, chills
• 5. vomiting, diarrhea
• 6. seizures
• 7. bulging fontanel in infants
• 8. cyanosis, mottled skin
• 9. neck and back pain
• 10. restless/irritable
• 11. lethargic
• 12. high pitched cry
• 13. anorexia, poor feeding
• 14. meningeal signs:  nuchal rigidity, pain upon neck flexion, photophobia, positive Kernig's/Brudzinski's sign
• 15. petechiae
• 16. purpura

• CBC - high WBC(bacterial)/meningococcal usually WBC <10,000
• BMP
• blood cultures
• clotting studies
• urinalysis
• CXR

known or suspected increased ICP

• 1. clear appearance
• 2. normal pressure
• 3. WBC <500
• 4. glucose and protein normal
• 5. negative gram stain

• 1. cloudy appearance
• 2. increased pressure
• 3. WBC >1000
• 4. decreased glucose and elevated protein
• 5. bacteria on gram stain

• 1. strict isolation:  mask, gown, gloves
• 2. undress completely - check skin
• 3. ABC's, O2, frequent VS, seizure precautions
• 4. IVs ASAP
• 5. antibiotics EARLY
• 6. antipyretics
• 7. monitor mental status
• 8. treat any family members/healthcare
• workers exposed if bacterial within 24 hours

women 65 and older

• 1. hyperlipidemia
• 2. CHF
• 3. obesity,
• 4. MVP
• 5. Afib
• 6. smokers
• 7. drug use (cocaine)
• 8. uncontrolled HTN

severity and predicts outcomes

0

brief symptoms that last seconds to 24 hours

progressive development of a deficit over time

immediate maximization of deficit - no improvement or decline

• 1. altered LOC
• 2. motor deficit: contralateral hemiparesis
•     or hemiplegia
• 3. sensory deficit:  contralateral
• 4. speech deficit:  dysphasia:  expressive,
•     receptive, or global
• 5. Visual deficit:  loss of vision in half of vision field

• 1. altered LOC
• 2. motor deficit in more than one limb
• 3. visual deficit:  field deficits, cortical         blindness, diplopia
• 4. Loss of coordination - cerebellum
• 5. cranial nerve deficit: 
•    *dysphonia - difficulty producing voice
•      sounds
•    *dysarthria - difficulty with articulation
•    *dysphagia - difficulty swallowing

• 1. non contrast CT scan within 25 min of ED arrival is goal
• 2. MRI
• 3. EKG
• 4. carotid Doppler studies

• 1. maintain ABC's
• 2. frequent neuro checks
• 3. HOB elevated in neutral in-line position
• 4. frequent VS - BP goal </= 185/110
• 5. anticoagulation - ischemic stroke only
• 6. mechanical clot retrieval procedures (FDA
•     approved for 8 hours from onset s/s)
• 7. IV tPA 
• 8. Intra-arterial tPA - not currently FDA
•     approved

within 60 min of ED arrival

within 3 hours of onset of s/s

90mg or 0.9mg/kg

10% of dose over 1 minute then rest of drug over one hour