Emergency Nursing

Question 1

What are the triage levels in the ED?

Answer 1

PAC1 - PAC4

Question 2

What constitutes as PAC1, including ABCDE?

Answer 2

• State of CVS collapse
• In imminent danger of collapse
• Req. immediate attention
  ___________________________
• Airway: Obstructed
• Breathing: Hypo/perventilation
• Circulation: Hemodynamic compromise or hemorrhage
• Disability: GCS<9
  _____________________________
  Cardiac arrest, Seizure, Shock, Acute stroke, Poly trauma

Question 3

What constitutes as PAC2, including ABCDE?

Answer 3

• Ill and non-ambulant, or in severe distress
• Not in imminent collapse
• Early attention needed to prevent deterioration
  ______________________________
• Airway: Patent
• Breathing: Mod distress
• Circulation: Mod compromise
• Disability: GCS 9-12
  ________________________________
  Asthma, Chest pain, Pregnant with bleeding, Testicular pains, Burns

Question 4

What constitutes as PAC3, including ABCDE?

Answer 4

• Ambulatory
• Acute mild to mod symptoms
• Requires acute treatment which will result in resolution of symptoms over time
  _______________________________
• Airway: Patent
• Breathing: Mild distress
• Circulation: Mild compromise
• Disability: GCS >12
  ____________________________
  Laceration, sore throat, sprains, diarrhea

Question 5

What constitutes as PAC4?

Answer 5

Non-emergency

Question 6

What are the triage levels in a disaster?

Answer 6

P0 - P3

Question 7

What constitutes as a P0 in a disaster?

Answer 7

• Unlikely to survive
• Palliative care
• Not breathing even after 5 rescue breaths

Question 8

What constitutes as P1 in a disaster?

Answer 8

• Immediate intervention and transport to hospital
• Compromised ABCD
• RR <10 or >30
  or
• HR >120 or CRT >2 sec

Question 9

What constitutes as a P2 in a disaster?

Answer 9

• Can afford delayed transport to hospital
• Have life-threatening injuries but is not expected to deteriorate significantly over the next few hours
• RR 10-29
• HR 120 or CRT<2 sec

Question 10

What constitutes as P3 in a disaster?

Answer 10

• Victims with minor injuries
• Unlikely to deteriorate within the next few days
• Ambulatory

Question 11

How does the ED prepare for a disaster?

Answer 11

• Recall staff and extend working hours
• Decant existing PAC1 and PAC2 px to ICUs and wards
• Discharge PAC3 when possible
• Deploy medical surgical trolleys
• Temporary equipment bays
• Satellite blood bank

Question 12

How does the ED prep for a trauma case? (pre-arrival)

Answer 12

• Pre-arrival code activated
• Based on ABC criteria >2, persistent hemodynamic instability, suspected active hemorrhaging that requires operation or angioembolisation
• SBP <90, HR>120, Fast, Penetrating torso injury
• Take hx from paramedics

AT MIST
- Age
- Time of incident

• Mechanism of injury
• Injuries sustained and suspected
• S/s
• Treatments performed

Question 13

How does the ED react in a trauma case? (arrival of patient - Airway)

Answer 13

• Primary survey with simultaneous resuscitation
• Airway maintenance with C spine immobilisation
• Breathing and ventilation
• Circulation with hemorrhage control
• Disability
• Exposure with environmental control

Question 14

How does the ED react in a trauma case? (arrival of patient - Breathing)

Answer 14

• Check if px can communicate
• Initiate suctioning
• Vital signs
• Early intubation especially if there are significant injuries to the face and neck that may lead to swelling of airway
• For volume depleted px, resuscitate and give fluids before intubation (intbn will inc ICP and red preload thus worsening hemorrhagic and obstructuive shock)
• Post intubation may have tension pneumothorax
• If no C spine immobilsation, can use head-tilt chin lift
• If have ^, jaw thrust or manual stabilisation

Question 15

How does the ED react in a trauma case? (arrival of patient - Circulation)

Answer 15

• Permissive hypotension (Avoid dislodgement of unstable clot by higher pressures) except for px with head injury
• Start hemostatic fluid resuscitation
• Damage control surgery (to control hemorrhage and minimize contamination)
• Apply direct pressure to bleeding sites
• Place 2 large bore peripheral venous catheters
• Baseline bloods
• Venous blood gas for base excess
• ECG
• Consider intraosseous (in bone) or central venous access in difficult IV access
• Use of E-FAST for hemorrhages to evaluate bleeding in pericardial, perihepatic and perisplenic spaces
• Massive transfusion protocol (MTP)
• Pack 1: 4 units RBC + 4 units FFP + 1 unit PLT + Tranexamic acid (anti-fibrinolytic) within 3 hrs of injury
• Pack 2: 4 units FBC + 4 units FFP + 1 unit PLT with cryoprecipitate (prevent dilution of clotting factors)

Question 16

How does the ED react in a trauma case? (arrival of patient - Disability)

Answer 16

• GCS
• Consider hypoglycemia, drug use, alcohol intoxication in px with altered mental state
• Basal fractures (raccoon eyes, Battle’s sign)

Question 17

How does the ED react in a trauma case? (arrival of patient - Exposure)

Answer 17

• Inspect for chest injuries (eg lacerations or ‘seatbelt sign’
• Flail chest or paradoxical breathing (chest goes in during inspiration)
• Palpate for subcutaneous edema or deformity
• Palpate for trachea deviation
• Auscultate for air entry
• Apply 3 way occlusive dressing for puncture wound
• Give supplemental O2, NRM for those SpO2 <92%
• Monitor SPO2
• CBG

Question 18

What is the secondary survey after improvements are seen?

Answer 18

AMPLE
- Allergies
- Medications using
- Past illness / pregnancy
- Last meal
- Events related to injury (timing and mechanism)
___________________________
- Re-evaluate px constantly
- Analgesia given in small doses (relieve pain and anxiety while avoiding respiratory status or hemodynamic changes)”