Emergency Flashcards
Triage Basic System
Emergent - life threatening
Urgent - serious but non life-threatening
Nonurgent - episodic illness, i.e. strep, UTI
Triage Emergency Severity Index (ESI)
Level 1 (emergent) - requires lifesaving interventions
Level 2 - high-risk situation (may become unstable), new altererd mental status, severe pain/distress
Level 3 (urgent) –> most pt’s in hospital, i.e. small bowel obstruction
Level 4
Level 5 (nonurgent)
What is a Primary Survey?
Focuses on stabilizing life-threatening conditions
ABCDE
Airway - establish
Breathing - adequate ventilation
Circulation - control hemorrhage, prevent shock, restore cardiac output
Disability - assess neuro function; AVPU (alert, verbal, pain, unresponsiveness)
Exposure - undress to assess wounds/injuries
What is a Secondary Survey?
After stabilization
Health history
Head-to-toe assessment
Diagnostics, labs
Monitoring - EKG, a-lines, catheters
What is AVPU
Quick way to assess neuro status during primary survey
Alert - is pt alert?
Verbal - does pt respond to verbal stimuli?
Pain - does pt respond to painful stimuli?
Unresponsive - is pt unresponsive to all stimuli?
What is an oropharyngeal airway?
semicircular tube that is inserted over back of tongue into lower posterior pharynx in a pt who is breathing spontaneously but unconscious
**prevents tongue from obstructing airway & allows for suction
What is a nasopharyngeal airway?
Same as OA but inserted through nares
*NOT TO BE USED if there is facial trauma or skull fx d/t risk of entering brain cavity
Endotracheal Intubation
Used on a pt who cannot be adequately ventilated with OA or NPA, to bypass upper airway obstruction, prevent aspiration, connect to ventilator, or for removal of tracheobronchial secretions
**placed by specially trained personnel, physicians
King Tube/Laryngeal Mask Airway
Typically used outside of hospital setting
Less invasive than ET tube
Balloon occludes esophagus
Cricothyroidotomy
Opening of cricothyroid membrane to establish an airway, used in emergencies where ET tube is not possible or CI (facial trauma, c-spine injury, laryngospasm, laryngeal edema)
Replaced with formal tracheostomy once stable
How do we assess adequate ventilation?
Bilateral breath sounds
O2 sats
Rise and fall of chest
ABG’s
Capnography (visual representation of exhaled Co2)
Patho of partial airway obstruction
Hypoxia –> Hypercarbia (high co2 in blood) –> respiratory arrest –> cardiac arrest
Patho of complete airway obstruction
Permanent brain injury or death occurs within 3-5 minutes
Causes of airway obstruction
- aspiration of foreign bodies
- anaphylaxis
- viral/bacterial infection
- trauma
- inhalation of chemical burns
Signs/symptoms of airway obstruction
Universal distress signal, refusing to lie flat, labored breathing, flaring nostrils, anxiety
Partial: pt is able to breathe and cough spontaneously; encourage coughing
Complete: weak, ineffective cough; high-pitched inhale, increasing respiratory difficulty, cyanosis
LATE signs of obstruction: cyanosis, loss of consciousness
Interventions for Airway Obstruction
ESTABLISH AIRWAY!
- reposition head to prevent obstruction with tongue
- head-tilt/chin-lift, insertion of equipment (OA, NPA, ET)
Monitor breathing
- chest movement, listen/feel for air movement
If partial obstruction - encourage pt to cough
Multiple Trauma
- what is it
- what to do
Single event that causes life-threatening injuries to at least two organs or organ systems
- ALWAYS assume c-spine injury until able to r/o
- establish priorities - ABC’s
What are intra-abdominal injuries?
Which organs are mostly affected?
Penetrating or blunt trauma to the abdomen
(GSW, stabs — MVAs, falls, blows, explosions)
hollow organ - small bowel
solid organ - liver
Intra-abdominal injuries
Assessment
Assess abdomen
Assess for external/internal bleeding (signs of shock, exp. if liver or spleen has been traumatized)
Referred pain –> left shoulder pain = spleen, right shoulder pain = liver
Intraperitoneal injury
Assess for GU injury - no indwelling catheter until after exam
Intra-abdominal injuries
Diagnostics
Labs - H&H trends, ABG’s, INR, WBC (increased w trauma)
CT abdomen
FAST - focused assessment w/ sonography for trauma: detects intraperitoneal bleeding
DPL - diagnostic peritoneal lavage: 1L of LR or NS into abdominal cavity, min. of 400mL return, send to lab, positive if high RBCs, WBCs, or presence of bile, feces, or food (no longer standard [CT preferred] but good+easy during mass casualties)
Intra-abdominal injuries
Management
ABC’s!!
Document all wounds
Maintain c-spine until injury is ruled out
If protruding viscera, cover w sterile, moist saline to keep wet and protect from infection
Keep NPO (no water)
GI suction to decrease risk of aspiration and decompress stomach for procedures/surgery
Give prophylactic tetanus and broad-spectrum abx
Rapid transport to surgery if needed
Crush Injuries
Assessment and Management
Assess:
- hypovolemic shock
- spinal cord injury
- fractures
- AKI !!
- hyperkalemia (crush injuries cause K+ to leave the cell)
Management:
- ABC’s
- observe for AKI
- severe muscle damage may cause rhabdo
- elevate injured extremity to relieve swelling & pressure
Hemorrhage
STOP BLEEDING!
Internal hemorrhage may not be visible
Assess for shock: low BP, tachycardia, delayed cap refill, decreased UO
External hemorrhage: direct firm pressure, elevate to stop venous bleeding, tourniquet
Give IV fluids or blood products
Heat Stroke
what is it? different types?
Acute medical emergency caused by failure of heat-regulating mechanisms of the body
Nonexertional - prolonged exposure to temps < 102.5
Exertional - strenuous activity in hot temps
Most at risk - old, very young, ill
Heat Stroke
Signs/Symptoms
Elevated body temp 105 F or higher
Delirium, confusion, seizures
Hot, dry, skin
Anhidrosis (absence of sweating)
Hypotension, tachycardia, tachypnea (shock)
Heat Stroke
Management
Reduce temp AS FAST AS POSSIBLE to 102 F
- cool sheets/towels, cooling blankets
- ice pack to neck, groin, chest, axillae
- immersion in cold water
Monitor CORE TEMP
STOP cooling at 100.4 F
Monitor VS, ECG, LOC
IV Fluids to replace fluid loss
Meds: anticonvulsants/benzos (seizures), potassium (hypokalemia), sodium bicarb (metabolic acidosis)
Frostbite
what is it? affects?
Trauma from freezing temps, freezing of intracellular fluid
Affects feet, hands, nose, ears
Frostbite
Assessment
Assessment:
- extremity may be hard, cold, insensitive to touch, may be white or mottled blue-white
- extent not always known
- get history: how cold, how long exposed, presence of wet conditions
Frostbite
Management
Goal: restore normal body temp
Controlled, rapid rewarming
- 37-40 C (98.6-104) circulating bath x 30-40 mins, repeat until circulation restored
Analgesics - very painful
DO NOT MASSAGE!
Hourly active motion after rewarming
Walking on affected extremities may exacerbate tissue damage
Hyperkalemia & hypovolemia are common with frostbite
Hypothermia
what is it? who is at risk?
hypothermia vs frostbite?
Internal core temp of 35 C (95 F) or less
Older adults, infants, ill, homeless, trauma victims
Hypothermia must be managed before frostbite!!
Hypothermia
Assessment
Physiologic changes occur in all organ systems
Shivering may be suppressed at temp < 32.2C (90F)
CO & BP may be so weak peripheral pulses become undetectable
Cardiac arrhythmias
Hypoxemia, acidosis
Hypothermia
Management
ABC’s, remove wet clothing, supportive care
Rewarming
- Active internal rewarming
- Passive external rewarming
Monitor core temp
Continuous ECG (cold-induced myocardial irritability leads to v-fib)
- cold blood returning from extremities has high levels of lactic acid and can cause dysrhythmias and electrolyte disturbances
Active Internal Rewarming
Used for moderate-severe hypothermia 28-32.2 C (82.5 - 90 F)
- cardiopulmonary bypass
- warm fluid administration
- warm humidified oxygen by ventilator
- warm peritoneal lavage
**Monitoring for v-fib as temp increases from 31-32C is essential
Passive Internal Rewarming
Used for mild hypothermia 32.2 - 35 C (90-95F)
- over-the-bed heaters to extremities
Poisoning - what is poison
Corrosive poisons
Treatment
Any substance that when ingested or inhaled injures the body by its chemical action
Corrosive poisons - alkaline and acid agents that can cause tissue destruction
Treatment
- remove or inactivate before absorbed
- provide supportive care
- administer antidotes if available
Poisoning
Assessment
ABCs
Monitor VS, LOC, ECG
Determine what, when, how much was ingested
Age and weight (for wt-based dosing)
Poisoning
Management
Measures to remove toxin or decrease absorption
- Emetics to induce vomiting (except with corrosives*)
- Gastric lavage
- Activated charcoal
*corrosive agents (acids and alkaline) cause destruction of tissues, DO NOT INDUCE VOMITING as this will cause further damage to upper airway; give milk or water to dilute
Carbon Monoxide Poisoning
- how does it happen
- signs/symptoms
Inhaled carbon monoxide binds to hemoglobin (which transports oxygen) into carboxyhemoglobin which does NOT transport oxygen
S/S: CNS –> headache, muscular weakness, palpitations, dizziness, confusion; may appear intoxicated
**skin color and pulse ox NOT valid bc there may be high hgb but it is saturated with carbon monoxide, not oxygen
Carbon Monoxide Poisoning
Management
Goal: reverse cerebral and myocardial hypoxia
Get fresh air ASAP!
CPR if necessary
100% oxygen given, preferably under hyperbaric pressures
- until carboxyhemoglobin is less than 5%
Prevent chilling, wrap in blankets
Chemical Burns
- what to do
- if dry chemical?
- follow up care
Immediately flush with water
If dry chemical (lye or white phosphorus), brush off skin before flushing
Always use PPE to protect self
Follow up care at 24 hrs, 72 hrs, 7 days [d/t risk of underestimating extent of injury]
Food Poisoning
Management
ABC’s –> botulism may results in respiratory paralysis or death
Determine source
Treat fluid and electrolyte disturbances
Control nausea and vomiting
Clear liquid diet and progression
Drug Overdose
Management
Support respiratory and cardiovascular function
Acute Alcohol Intoxication
Management
Maintain airway
Observe for CNS depression
Rule out other causes - head injury, hypoglycemia, hypoxia, hypovolemia
Nonjudgmental, calm
Trauma
- collection of evidence
Document description of all wounds, mechanism of injury, time of events, collect evidence
Be careful with removing clothing - try to maintain evidence
Place items in paper bag; plastic bags retain moisture & can destroy evidence
Cover pt’s hands with paper bags to protect evidence on hands/under fingernails
Document pt’s words in quotations
Sexual Assault
Management
Provide support
Reduce emotional trauma
Gather available evidence (paper bags)
SANE nurses - sexual assault nurse examiners
Treat consequences
- STIs, prophylactic treatment
- pregnancy, antipregnancy meds
Encourage follow up care
Human Trafficking
- signs to look out for
- common complaints
Pt may be accompanied, look to them for answers
Hx of chronic runaway, homelessness, self-mutilation
Common behavior: cowering, frightened, agitated
Common complaints: injuries, poor healing, abd pain, dizzy, HA, rashes, sores
Psychiatric Emergencies
Maintain safety, gain control of situation
Determine if pt is at risk for injuring self or others
Nonfatal Drowning
- define
- management
Survival for at least 24 hours after submersion that caused respiratory arrest
Maintain cerebral perfusion and adequate oxygenation
Decompression Sickness
- define
- s/s
- treatment
Occurs in pt’s who have enaged in diving, high-altitude flying, or flying in commercial aircraft within 24 hours after diving
S/S: joint pain, numbness, loss of ROM
Must transfer to hyperbaric chamber
Animal and Human Bites
Cat bites have high risk of infection (pasteurella in saliva)
Human bites contain more bacteria than that of most other animals - high risk of infection
Assess for infection, collect evidence, cleanse with soap and water, abx and tetanus
Snakebites
Medical emergency
S/S: edema, ecchymosis, necrosis, n/v, numbness, metallic taste
Tx: lie down, remove constricting items, cleanse wound, cover with sterile dressing, immobilize below heart
Antivenin most effective given within 4 hours, no greater than 12 hours
Spider bites
- brown recluse
- black widow
Brown recluse
- painless
- sx develop within 24-72 hrs: fever, chills, n/v, joint pain
- necrosis in 2-4 days
Black widow
- system effects occur within 30 mins
- s/s: abdominal rigidity, n/v, hypertension, tachycaardia
- severe pain: analgesics and benzos
