Emergency Situations Flashcards
1
Q
What 3 questions can be asked to establish a framework for quickly developing an emergency plan of care?
A
- What do i know about my patient?
- what do i know about the procedure?
- what do I know about my available resources?
2
Q
Since 1963, what society has used a predictive system of classification for anesthetic outcomes for preoperative patients?
A
American Society of Anesthesiologists
3
Q
What do the ASA classifications range from?
A
ASA I to ASA VI
4
Q
ASA I is what?
A
healthy individual
5
Q
ASA VI is what?
A
an individual who has been declared brain dead and is being prepared for organ donation
6
Q
What does the E following ASA classifications III, IV, and V designate?
A
the procedure as an emergency, requiring immediate action
7
Q
What does the ASA classification help to do?
A
the starting point for multidisciplinary teams to prioritize staff and equipment and to anticipate potential complications during the surgical procedure
8
Q
elective procedures allow for what?
A
allow the patient and perioperative team members adequate time to prepare for the surgery
9
Q
urgent procedures are performed when?
A
performed for conditions that are not considered life-threatening but could progress to an emergency status if not treated
10
Q
a time frame for urgent procedures is followed based on what?
A
the nature of the condition and the associated complications (i.e. compound fracture and risk for infection)
11
Q
emergency procedures are what?
A
nonelective surgeries performed when time is a factor in saving a patient’s life or limb
12
Q
The acute nature of emergency procedures means what?
A
means that less time can be spent conducting a thorough patient assessment or following typical protocols (surgical counts, informed consent)
13
Q
what is the focus of emergency procedures?
A
to save the patient’s life and prevent systemic deterioration
14
Q
What is the definition of ASA I
A
a normal, healthy patient
15
Q
what are examples, including but not limited to ASA I?
A
healthy, nonsmoking, no or minimal alcohol use
16
Q
What is the definition of ASA II
A
a patient with mild systemic disease
17
Q
What are examples, including but not limited to ASA II?
A
- mild diseases only without substantive functional limitations
- current smoker, social alcohol use, pregnancy, obesity (30 < BMI <40), well controlled DM/HTN, mild lung disease
18
Q
What is the definition of ASA III?
A
a patient with severe systemic disease
19
Q
What are examples, including but not limited to ASA III?
A
- Substantive functional limitations; one or more moderate to severe diseases
- Poorly controlled DM or HTN, COPD, morbid obesity (BMI>40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate ejection fraction reduction, ESRD undergoing regularly scheduled dialysis, premature infant PCA < 60 weeks, history (> 3 months) of MI, CVA, TIA, or CAD/stents
20
Q
What is the definition of ASA IV?
A
a patient with severe systemic disease that is a constant threat to life
21
Q
What are examples, including but not limited to ASA IV?
A
Recent (<3months) MI, CVA, TIA, or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of ejection fraction, sepsis, DIC, ARD, or ESRD not undergoing regularly scheduled dialysis
22
Q
What is the definition of ASA V?
A
a moribund patient who is not expected to survive without an operation
23
Q
What are examples, including but not limited to ASA V?
A
ruptured abdominal/thoracic aneurysm, massive trauma, intracranial bleed with mass effect, ischemic bowel in the face of significant cardiac pathology or multiple organ/system dysfunction
24
Q
what is the defintion of ASA VI?
A
a declared brain-dead patient whose organs are being removed for donor purposes
25
MH is a what? associated with?
a potentially fatal hyermetabolic complication associated with a rare autosomal dominant genetic defect
26
what triggers MH?
volatile inhaled anesthetics and the depolarizing muscle relaxant succinylcholine
27
What kind of anesthetics trigger MH?
those that end in "ane"
28
How does MH start?
the triggering agent initiates a release of large amounts of calcium in skeletal muscle cells, resulting in sustained muscle contractions, a hyper metabolic state, and heat production
29
What are the first signs of an MH crisis?
an increase in end tidal CO2 and tachycardia are the first signs
30
What may also show up when an anesthesiologists trys to intubate a patient with MH?
sustained muscle rigidity may be manifested by difficulty intubating
31
What may the surgeon note with MH at the field?
dark unsaturated blood at the surgical field
32
What are other s/sx of MH?
1. hypertension
2. mottling of the skin
3. cola-colored urine
4. hyperkalemia
5. metabolic and respiratory acidosis
6. ventricular arrhythmias
33
What is a late sign of MH?
an extreme rise in body temp (over 110 degrees F)
34
What are severe complications of MH?
cardiac arrest, brain damage, systemic organ failure, and death
35
What patient population should a nurse/provider not use triggering agents for MH in?
patients with underlying muscle conditions (muscular dystrophy, myotonia) or a family history of unexplained death during general anesthesia
36
What are the 12 steps for treatment of MH?
1. notify the surgeon to stop the procedure ASAP. If surgery must be continued, assist the anesthesia care provider to exchange inhaled anesthesia agents to IV non triggering agents
2. discontinue volatile agents and succinylcholine
3. get dantrolene and the MH cart
4. call for help (MH code) or 911 per facility protocol
5. Hyperventilate with 100% Oxy at flows of 10 L/min to flush volatile anesthetics and lower EtCO2, if availabile, insert activated charcoal filters into the inspiratory and expiratory limbs of breathing circuit. The filter may become saturated after 1 hour; therefore, a replacement set of filters should be substituted after each hour of use
6. initiate additional venous access with a large bore IV catheter if possible. Give IV dantrolene 25 mg/kg rapidly and repeat as frequently as needed until the patient responds with decreased etCO2, decreased muscle rigidity, and a lowered heart rate. Large doses (>10mg/kg) may be required for patients with persistent contractures or rigidity
7. assist with the insertion of an arterial line. send blood gas specimens (venous or arterial) as ordered
8. relay lab results to the surgical team
9. assure additional meds are available (calcium chloride or calcium gluconate, insulin, sodium bicarb)
10. insert a 3 way foley
11. cool the patient if his or her core temp is greater than 102 degrees fahrenheit (39 degrees celsius) or if it is less but rapidly rising. Stop cooling when the patient's temperature has decreased to less than 100.4 degrees (38 degrees)
12. When stabilized, arrange for transport to the ICU
37
At the onset of MH symtpoms, think what?
SHS-Cool
38
What does SHS cool stand for?
first action: STOP the inhalant anesthesia and STOP the surgery
Second action: HYPERVENTILATE the patient with 100% oxygen
Third action: START dantrolene
Fourth action: COOL the patient
39
When does LAST occur?
when toxic amounts of a local anesthesia agent enter the bloodstream
40
LAST is based on 3 major risk factors?
1. impaired renal or hepatic function, which interferes with drug metabolism and excretion;
2. an inadvertent injection of local anesthetic into a highly vascular tissue or bloodstrem
3. an amount of drug injected exceeding the max recommended dosage
41
What s/sx of LAST typically occur before the other?
CNS signs and symptoms typically occur before cardiovascular manifestations
42
What are s/sx of LAST related to
directly related to the patient's blood concentration of the drug
43
s/sx of LAST typically occur within what?
1 minute of administration of the local anesthetic agent, and, if left untreated, can be life-threatening
44
what can be included in the timeout to help prevent LAST?
incorporating dosing parameters and patient-specific maximum doses for local anesthetics as part of the time out
45
What should be monitored in combination with documentation of what with local anesthetic?
local anesthetic dosages should be monitored and documented along with the patient's reaction to the medication
46
Constant monitoring of patient receiving local anesthetics does what?
helps to detectm CNS and cardiovascular changes indicative of a LAST reaction
47
What is a method that can be used for assessing early signs and symptoms of an impending LAST event?
verbal contact
48
Treatment of LAST includes what?
1. immediately stop injection of the local anesthetic
2. secure the patient's airway
3. ventilate the patient with 100% oxygen
4. call for help
5. establish IV access if not already present
6. Prepare to administer basic and advanced life support as the patient's condition warrants
7. Treat seizure activity with benzodiazepines
8. be prepared to administer lipid emulsion therapy (20% lipid emulsion)
49
What are initial phase signs and symptoms related to the CNS with LAST?
1. metallic taste
2. confusion
3. dizziness
4. drowsiness
5. light-headedness
6. numbness and tingling of the lips and tongue
7. tinnitus
8. nystagmus
50
What are excitation phase signs and symptoms related to the CNS with LAST?
1. agitation
2. tremors
3. tonic-clonic convulsions
51
What are depression phase signs and symptoms related to the CNS with LAST?
1. unconsciousness
2. respiratory arrest
3. coma
52
What are initial phase signs and symptoms related to the cardiovascular system with LAST?
1. hypertension
2. tachycardia
53
What are intermediate phase signs and symptoms related to the cardiovascular system with LAST?
1. decreased cardiac output
2. mild to moderate hypertension
3. myocardial depression
54
What are terminal phase signs and symptoms related to the cardiovascular system with LAST?
1. hypotension
2. peripheral vasodilation
3. sinus brady
4. ventricular dystrhythmias
5. cardiovascular collapse
6. asystole
7. death
55
Where can an air embolism form?
either the venous or arterial circulation
56
when does a venous air embolsim form?
occurs when an opening in the venous system has a lower pressure gradient that than the atmosphere, which results in air being drawn into the venous circulation and potentially lodging in a blood vessel
57
What are the 2 types of procedures with an increased risk of air embolism?
1. cases in which the surgical site has a lower pressure gradient than the atmosphere (procedures conducted in a sitting position)
2. laparoscopic procedures when insufflating gas is instilled under pressure to create a pneumoperitoneum
58
What are 3 other miscellaneous things that can result in an air embolism?
1. access of air to the circulation via a central line
2. access of air to the circulation via a hemodialysis catheter
3. during cardiopulmonary bypass
59
What is more often a complication of cardiac surgery?
arterial air embolism (AAE)
60
When the patient is placed on an extracorporeal circuit to oxygenate the blood, what is most susceptible to air being infiltrated into the system?
the arterial portion of the circuit
61
AAE may occur as a result of what 3 things?
1. air bubbles in the arterial inflow line or in the cardiac chambers becoming dislodged after the heart resumes beating
2. chest trauma when air from the bronchial veins enters the left atrium
3. venous air passing through a cardiac defect (i.e. patent foramen ovale) and entering the arterial circulation
62
what is believed to be the most effective in reducing the concentration of local anesthetic in the blood?
lipid emulsion
63
what is one of the main ingredients in lipid emulsion?
egg
64
So what should patients be screened for preoperatively if we know that a patient is scheduled for a procedure with local anesthetic?
screened for an egg allergy
65
What are the first 2 symptoms of an air embolsim?
decreased end-tidal CO2 and lower oxygen saturation
66
What are 3 s/sx of a VAE?
1. rise in pulmonary artery pressure
2. decreased cardiac output
3. tachy or bradyarrhythmias
67
What do s/sx of Cerebral VAE's depend on?
what portion of the brain was affected
68
signs and symptoms of an AAE involve what?
the cardiac system
69
What kind of s/sx can you expect with a patient who has an AAE?
1. hypotension
2. tachy or bradyarrhythmias
3. cardiac arrest
4. see respiratory symptoms as well
70
Patients who are awake with an AAE might be complaining of what?
1. shortness of breath
2. back, chest, or shoulder pain
3. exhibit changes in mental status
4. OR may have seizures
71
What are nursing interventions for VAE or AAE's?
1. risk factors for a VAE or an AAE (i.e. position, procedure) should be identified during the preoperative assessment and included in the time out
2. Monitoring devices (i,e. central venous pressure catheter, precordial or transcranial doppler probe, end tidal CO2 monitor, transesophageal echocardiography machine) should be available
3. All lines should be inspected for air bubbles and loose connections
72
If an air embolism is suspected, what will the anesthesia care provider do?
will increase the fraction of inspired oxygen to 100% and stop the flow of nitrous oxide, if being used
73
In order to restore the patient's hemodynamic stability and oxygen saturation, the circulating nurse will do what:
1. call for help
2. in collaboration with the scrub person, anesthesia care provider, perfusionist, and surgeon, identify and close the entry point for the air embolsim
3. Assist with the insertion of a central venous or pulmonary artery catheter if not already in place
4. Temorarily place the patient in the left lateral (durant maneuver), slight trendelendburg position to allow entrapped air to collect in the apex of the right ventricle and be removed via central venous or pulmonary artery catheterization
5. remove air directly from the heart during open chest procedures via a syringe and needle
6. perform chest compressions to force air through air locks in the heart (the patient does not need to be in cardiac arrest)
7. assure vasopressors (dobutamine, norepi) are available
8. arrange for hyperbaric oxygen therapy as needed and transfer to the ICU
74
What is a bronchospasm?
a sudden constriction of the bronchioles
75
What are the most common causes of a bronchospasm?
1. preexisting chronic pulmonary lung disease
2. allergies
3. anaphylaxis
4. aspiration of a foreign body
76
What are signs and symptoms of bronchospasm?
1. may demonstrate cough
2. expiratory wheezing
3. use of accessory muscles
4. tachypnea
IF LEFT UNTREATED, CAN PROGRESS TO RESPIRATORY ARREST
77
What are nursing interventions for bronchospasm?
1. the RN should prepare for immediate retrieval of an aspirated object via bronchoscopy
2. acquire additional support - including oxygen therapy, inhaled bronchodilators, and treatment of an allergic response or anaphylaxis as indicated
78
What may a patient with a bronchospams require?
reintubation and ventilatory support
79
What is not used in neurosurgery or cardiac surgery?
nitrous oxide
80
Why is nitrous oxide not used in neurosurgery or cardiac surgery?
because of the ability of its molecules to expand rapidly, potentially creating a VAE
81
What is a laryngospasm?
is a partial or total closure of the vocal cords caused by secretions on the vocal cords or irritation of the laryngeal reflexes
82
When is a laryngospasm most commonly seen?
upon extubation after procedures
83
Why is a laryngospasm most commonly seen upon extubation?
because a large collection of fluids or blood have pooled in the pharynx (i.e. tonsillectomy, dental work)
84
Who are most at risk for developing a laryngospasm?
children under the age of 5 years and patients with an irritable airway
85
Who are patients with irritable airways?
1. asthmatics
2. smokers or those living in a household with someone who smokes
3. someone with a recent upper respiratory infection
4. someone who underwent vigorous posterior oral suctioning following extubation
86
What are signs and symptoms associated with partial laryngospasm?
a crowing sound accompanied by paradoxical movement of the chest or abdomen
87
What are signs and symptoms associated with a complete laryngospasm?
1. the patient will have no breath sounds and paradoxical movement of the chest or abdomen
2. oxygen saturation decreases
3. pCO2 increases
88
What are 2 preventative laryngospasm nursing interventions?
1. laryngospasm risk factors (i.e. patient age, type of procedure, irritable airway) are identified during the preoperative assessment and communicated to the surgical team during the time out
2. Emergency drugs and the difficult airway cart should be immediately available
89
What is required immediately with laryngospasm?
Immediate intervention is required to prevent the patient from going into respiratory and cardiac arrest
90
What are immediate steps when a laryngospasm is identified?
1. a chin lift/jaw thrust should be performed
2. patient should be ventilated with 100% oxygen under positive pressure via a bag valve mask
3. suction should be immediately available to remove secretions
4. if the patient cannot be ventilated, the RN should call for help
5. the RN should eb prepared to assist with the administration of propofol to deepen anesthesia and relax the vocal cords
6. bag-valve-mask respiratory support will need to continue until the patient is able to breathe spontaneously
7. the RN should be prepared to assist with administering succinylcholine for a complete laryngospasm not relieved within 1 minute
8. reintubation may be necessary
9. the receiving unit should be notified of the event and be prepared with humidified oxygen, racemic epi nebulizer treatments, and corticosteroids
91
What is anaphylaxis?
a rapid, severe, systemic, immediate allergic response secondary to exposure of a sensitized person's immoglobulin E to an environmental antigen
92
In perioperative patients, what is the most frequent anaphylactic reactions?
involves antibiotics, blood products, and natural rubber (latex)
93
How does an anaphylactic reaction occur?
1. It begins with the production of sensitized IgE after repeated exposure to an allergen.
2. Subsequent exposure results in binding of the allergen with receptor sites on the IgE present on the surface of mast cells, which are key components of the inflammatory process
3. the binding of the IgE receptor with the mast cell results in degranulation (release) of mediators from the mast cell, notably histamine.
94
What is most responsible for the signs and symptoms of both an allergic and anaphylactic reaction?
histamine release (itching, vomiting, diarrhea, bronchial constriction, vasodilatation
95
What is the best treatment of an anaphylactic crisis?
prevention
96
All patients should be assessed prior to the start of an operative or invasive procedure for what?
for reactions to drugs, food, tape, soaps, and latex
97
What should 2 things should be documented and communcated to other perioperative team members? as far as allergic reactions
1. the type and severity of the reaction
2. what was done to relieve its signs and symptoms
98
What might a patient be given signifying the presence of an allergy?
color coded wrist band
99
what should be removed from the patient's environment to avoid anaphylaxis?
all triggers
100
what should be readily available in case a patient has an anaphylactic reaction?
emergency meds and supplies
101
What should be included as part of the presurgical time out, documented, and communcated during hand off?
allergies
102
What should be verified before dispensing any meds?
patient allergies
103
What are the actions that should be taken to treat an anaphylactic response?
1. remove the causative agent
2. call for help
3. provide the anesthesia care provider with emergency medications (i.e. epi, corticosteroids, histamine blockers, vasopressors, diphenhydramine) and emergency equipment and supplies (i.e. code cart, difficult airway cart, fiberoptic bronchoscope, transesophageal echocardiscope, video laryngoscope)
4. initiate basic or advanced cardiac life support as necessary
104
What does an immune-mediated response to an antibiotic involve?
the binding of a drug and IgE complex with mast cells
105
as mast cells degranulate, what happens?
histamine and other inflammatory mediators are released into tissues
106
What are the most common antibiotics implicated in an allergic response?
B lactams (penicillins, cephalosporins, carbapenems, monobactams) - but a true anaphylactic reaction is rare
107
antibiotics given how are more likely to cause more serious allergic reactions?
drugs given IV
108
What is the most common sign of an antibiotic allergic reaction?
a rash
109
what are anaphylactic s/sx to antibiotics?
1. urticaria
2. angioedema
3. bronchospasm
4. gastrointestinal symptoms
5. hypotension
110
What is the most effective strategy for the management of a drug allergy?
avoidance of the drug
111
What should be obtained during the preoperative assessment when it comes to antibiotics?
info regarding a previous reaction to an antibiotic (name of drug, dose, route of admin, signs and symptoms, treatment)
112
If an adverse reaction to an infusing antibiotic is suspected, what should happen?
the infusion should be stopped immediately
113
Signs and symptoms of anaphylaxis to antibiotics should be treated with...
epinephrine, supplemental oxygen, antihistamines, and steroids
114
Systemic involvement of the respiratory and circulatory systems in anaphylaxis is managed with what?
basic and advanced cardiac life support
115
What should be documented and communicated to other health care team members following an anaphylactic reaction to antibiotics?
reaction, treatment, and patient response
116
Who should the patient be referred to following an anaphylactic reaction to an antibiotic?
an allergist to confirm an IgE-mediated allergy
117
Misdiagnosing an antibiotic allergy does what? Which does what?
displaces first-line antibiotics for prophylaxis which can result in increased risk for surgical site infections and antibiotic resistance
118
What is the most common cause of an acute hemolytic reaction?
ABO incompatibility between the donor and recipient
119
What happens in an acute hemolytic reaction
the recipient's antibodies bind with the donor's red blood cells (antigens), lysing the red blood cells and initiating the inflammatory response
120
What can fragments of lysed cells cause?
they can block kidney tubules and blood vessels, resulting in renal failure
121
What are classic signs and symptoms of a blood transfusion reaction?
1. fever
2. chills
3. headache
4. flank pain
122
What may be some of the first symptoms of an AHR in an anesthetized patient?
1. hyperthermia
2. hypotension leading to shock
3. hemoglobinuria
4. systemic hemorrhage
123
most transfusion reactions result from what?
a system failure
124
Before any blood product is transfused what must be verified?
the label, patient name, blood type, and ABO group must be verified
125
If an AHR is suspected, the RN should do what?
assist the anesthesia care provider
126
What does management of an AHR include?
1. immediately stop the infusion
2. call for assistance
3. replace the IV tubing and begin an infusion of normal saline
4. Report the AHR to the surgeon and blood bank
5. anticipate orders for antihistamines and a urinalysis
6. return unused blood product and IV tubing to the blood bank
7. complete an occurrence report; a copy will be transmitted to the blood bank
127
What does a latex allergic response involve?
involves IgE latex-sensitized antibodies reacting to a natural rubber proteins in latex products (gloves, catheters)
128
What do mild signs and symptoms of a latex allergy involve?
1. skin redness
2. dryness
3. itching
129
If latex proteins are airborne, mild reactions may include what?
rhinitis; sneezing; and itchy, watery eyes
130
Systemic reactions to latex include what?
1. laryngospasm
2. bronchospasm
3. laryngeal edema
4. tachycardia
5. hypotension
6. respiratory distress
7. anaphylactic shock
131
A thorough patient history of reactions to what should be done in regards to latex?
1. latex products (catheters, balloons, gloves)
2. food (apple, banana, kiwi, chestnut, avocado, papaya, raw potato, tomato
132
Other risk factors for latex include what?
1. conditions - spina bifada - requrining surgeries and multiple exposures to latex products (frequent urinary catheterizations)
2. asthma
133
Patients with a latex allergy should be identified through what?
a wristband and documentation on the medical record
134
What are 3 actions to ensure a latex-safe environment of care?
1. removing products that contain latex from the room
2. posting signs on the doors of the OR
3. includes appropriate hand-over (hand-off) communication that the patient has a latex sensitivity or allergy
135
Medications for the treatment of latex include what?
1. epinephrine
2. diphenhydramine
3. corticosteroids
136
true or false; If the patient has a B-agonist inhaler, it should accompany the patient to PACU
true
137
What is the definition of cardiac arrest?
is defined as the cessation of cardiac activity with concurrent loss of circulation
138
What are the reasons the heart may cease functioning?
1. shock
2. hemorrhage
3. respiratory arrest - pulmonary emboli, laryngospasm
4. metabolic causes - acid base or electrolyte abnormalities
5. anaphylaxis
6. a response to drugs or anesthetic agents
7. direct trauma to the heart
139
What are the 4 types of cardiac arrest?
1. asystole
2. pulseless electrical activity (PEA)
3. ventricular fibrillation (VF)
4. Ventricular tachycardia (VT) without a pulse
140
General anesthesia and surgery contribute contribute to what?
major cardiac complications because of the potential for myocardial stress and central venous and arterial pressure decreases
141
Induction of general anesthesia may lead to what in blood pressure?
may lead to a substantial reduction in blood pressure and cardiac output
142
What may lead to significant raise in blood pressure?
1. endotracheal intubation
2. an arterial vasospasm
3. increased catecholamine release
143
What will an ECG monitor show when a patient is in cardiac arrest?
either a flat line or electrical activity incompatible with life
144
What will be absent in cardiac arrest?
breath sounds, pulse, and blood pressure
145
How will the skin be in cardiac arrest?
cold, clammy, and cyanotic
146
How will blood be at surgical site in cardiac arrest?
dark in color
147
It is important to determine what with cardiac arrest?
if rhythm is shockable versus nonshockable
148
What are shockable rhythms?
VT and VF
149
What are nonshockable rhythms?
asystole and PEA
150
What are risk factors for cardiac arrest?
1. extremes in age
2. history of heart arrythmias or cardiac disease
3. type of procedure
4. patient position during the procedure
151
Based on the patient's condition, the RN should plan on having available what for cardiac arrest?
1. invasive monitoring devices (arterial line, central venous cath)
2. the cardiac defibrillator
3. emergency drugs
4. consider putting the cardiac code cart outside the room
152
true or false; depending on the patient's condition and procedure, defibrillator pads may be placed on the patient prior to induction.
true
153
What should be avoided during induction to prevent activation of the sympathetic nervous system (cardiac arrest)
loud noises and patient movement
154
What should be avoided during patient positioning (cardiac arrest)
rapid changes in circulatory blood volume
155
In the event of a cardiac arrest, the RN should be prepared to do what?
1. initiate cardiopulmonary resuscitation
2. call for help
3. obtain the emergency cart and defibrillator
4. assist the anesthesia care provider with airway management and meds
5. maintain IV access
6. monitor vital signs - including end tidal CO2
156
Strategies to reduce the risk of fire will protect who?
health care team members and the patient
157
Surgical patients are at risk of fire injury because of what?
the proximity of all 3 elements of the fire triangle
158
what are the 3 elements of the fire triangle
fuel, oxygen, and an ignition source
159
Who are at highest risk for fire injury?
patients having surgery on the head, neck, and upper chest are at highest risk because these surgical sites are closest to the patient's airway
160
what delivers oxygen, producing an oxygen-enriched environment?
ET tube, mask, or nasal cannula
161
Although most OR fires occur on the patient, the RN should be alert to what?
other sources of fire - electrical quipment
162
The RN should conduct what kind of assessment at the beginning of each procedure and include the results of the assessment during the presurgical time out?
fire risk assessment
163
Communication of a fire risk assessmnet should center on the present and containment of what 3 things?
1. source of oxygen in use
2. electrosurgical unit pencils, lasers, and other ignition source s
3. combustible products and fuel sources (drapes, sponges)
164
alcohol based skin prep solutions must be given what?
adequate time to dry before draping the patient
165
surgical drapes should be assessed for what in regards to fire?
for pooling of flammable prep solutions and removed if needed
166
the surgical team should follow what to prevent fires?
fire safety recommndations for surgical devices and equipment according to manufacturers instructions for use
167
What 4 questions should be asked and answered during the presurgical time out to evaluate the risk for an intraopertive fire?
1. Is an alcohol based skin antiseptic or other flammable solution being used?
2. Is the operative or other invasive procedure being performed above the xiphoid process or in the oropharynx?
3. Is oxygen or nitrous oxide being administered via nasal cannula or mask?
4. Is an energy-generating device (laser, ESU, fiberoptic light) being used?
168
What is RACE
a mnemonic for the sequence of steps to take should a fire occur
169
What does RACE mean?
rescue, alarm or alert, contain or confine, and extinguish or evacuate
170
What is the deeper meaning of rescue?
Rescue those in immediate danger. All surgical team members should work cooperatively to turn off the oxygen and other gases, disconnect power sources, pour saline on drapes, move the back table, remove burning drapes, assess for secondary fires, and move the patient as needed.W
171
How should patients be moved during fire?
based on predetermined evacuation routes - horizontal or lateral
172
What is the deeper meaning of alarm or alert?
alarm or alert others to the emergency. Personnel should pull the fire alarm and call for help
173
What is the deeper meaning of confine or contain?
confine or contain the fire. Personnel should keep the doors to the OR closed and put moistened towels at the bottom of the door to keep smoke from escaping into the corridor
174
What is the deeper meaning of extinguish?
extinguish with a fire extinguisher or pour normal saline on nonelectrical fires.
175
What are the 3 classes of extinguishers?
A. B. C.
176
What is the use of class A fire extinguishers?
wood, paper, cloth, rubber
177
What is the use of class B fire extinguishers?
liquids, grease
178
What is the use of class C fire extinguishers?
electrical fires
179
What is very important when little may be known about an unresponsive trauma victim?
understanding the mechanism of injury provides valuable information the perioperative team in preparing to care for the patient.
180
What are the 3 mechanisms of injury (MOI)?
blast, blunt, or thermal injury
181
The perioperative takes advantage of what with trauma
the golden hour
182
What is the golden hour?
the time immediately following trauma during which surgical interventions have the best change of preventing death or disability
183
What is a blast injury caused by?
caused by a bomb, bullets, or stabbing instrument that separates, stretches, compresses, or shears cells
184
The extent of injury in blast injury traumas is dependent on what?
the nature of the foreign object (i.e. bullet caliber, knife size) and velocity of the force used
185
What may happened beyond the primary blast site?
debris, projectiles, and other secondary, tertiary, and even quaternary injuries may occur
186
Where do we often see blunt injuries?
in motor vehicle collisions, sports injuries, and falls.
187
Blunt injuries represent what?
acceleration, deceleration, shearing, compression, or any combination of forces that do not break the skin
188
What are higher morbidity and mortality with blunt injuries related to?
difficulty in identifying these less obvious injuries
189
tissue or inhalation can occur from what?
a fire or burn
190
What is one of the priorities for the perioperative team?
normothermia
191
Burns compromise what?
the thermal protection that intact skin provides
192
When perioperative personnel are notified that a patient with a burn is coming to the OR, what should happen?
separate rooms should be prepared in the preoperative and postanesthesia care unites and the temperatures in those rooms should be raised.
193
If separate rooms are not available for a patient that has burns what should happen?
the surgical team should be prepared to accept that patient directly into the OR and to transfer the patient to the ICU directly after surgery
194
What is the first action of the OR team for a thermal injury patinet?
the surgical team should raise the temperature in the OR and have warmed IV and irrigation and solutions immediately available
195
The RN circulator should ensure what for thermal injury patients?
should ensure that forced-air, temperature regulating blankets are available
196
The RN circulator should also be prepared to maintain what?
the temperature of the patient's head and extremities if possible
197
After ascertaining the MOI, the surgical team can use what alphabetical mnemonic as a mental checklist for assessing a trauma patient...
A (Airway), B (Breathing), C (Circulation), D (Defribrillation), D (Disability), and E (Exposure)
198
Perioperative nurses must prepare for the trauma patient by ensuring availability of what?
emergency carts, instruments, supplies, and positioning equipment while collaborating with all teams involved to assure everyone's needs are met
199
If there isn't a lot of time what can the RN do as far as skin antisepsis?
RN may perform an abbreviated skin prep
200
True or false: instruments, soft goods, and sharps may not be counted if the count would delay the patient's treatment. IF TIME ALLOWS, A SURGICAL COUNT SHOULD ALWAYS BE PERFORMED
true
201
What are the four tests performed to assess the type and extent of an injury?
1. computed tomography
2. diagnostic peritoneal lavage
3. focused assessment with sonography for trauma (FAST)
4. ultrasonography
202
What does the trauma team use to determine the severity of neurologic injury?
glasgow coma scale
203
What 3 components does the Glasgow Coma scale have?
1. the patient's eye opening and pupillary reactions
2. verbal responses (i.e. incomprehensible words)
3. motor responses (i.e. present or absence of posturing
204
The revised trauma score adds what to further assess the patient's neurological status?
respiratory rate and systolic blood pressure
205
What are the standard indicators of possible spinal cord injury?
1. absence of rectal tone
2. bradycardia in the presence of hypotension
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What do health care providers focus on with possible spinal cord injury?
maintaining head and spine stability and carefully logroll the patient when repositioning
207
What may be used to treat increased intracranial pressure?
mannitol
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What are other nonpharm interventions for increased intracranial pressure?
1. elevating the head of the bed 30 degrees
2. keeping the patient's head midline to promote venous drainage
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What is a common complication of trauma?
hemorrhage - abnormal loss of blood
210
uncontrolled bleeding may progress to what?
hypovolemic shock
211
What is hypovolemic shock?
the circulatory system is unable to perfuse tissues to adequately meet oxygen requirements
212
a decrease in cardiac output ultimately leads to what?
cardiovascular collapse
213
What is the most preventable cause of death in trauma victims?
hemorrhage
214
Hemorrhage can also result from what 4 things?
injury to vessels during surgery, clotting disorders, hepatic disease, and obstetric hemorrhage
215
what is the most serious complication of childbirth and remains a major cause of maternal mortality?
hemorrhage
216
What are 3 indicators of decreased circulating blood volume?
1. hypotension
2. elevated heart rate
3. decreased urine output
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What may the skin look like when someone is hemorrhaging?
may appear pale or cyanotic
218
What may blood at the surgical field look like when someone is hemorrhaging?
may appear dark due to oxygenated blood
219
Loss of blood volume leads to what?which contributes to what?
leads to compensatory vasoconstriction, which contributes to hypothermia
220
What 2 things can RN's do before surgery to prevent hemorrhage?
1. asses patient risk factors related to bleeding (i.e. abnormal clotting times, low hematocrit values, history of bleeding or blood dyscrasias, anticoagulant use, planned major vascular procedure, trauma)
2. assure that blood or blood products have been ordered and are available
221
The RN should anticipate what to prevent hemorrhage?
1. the need for blood transfusion equipment
2. an intraoperative cell salvage machine
3. a rapid fluid infuser
4. heated IV infusion line
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What is the most important step for the surgical team in resuscitating a patient who is experiencing hemorrahge?
to identify and control the source of bleeding rapidly
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How can identifying and controling the source of bleeding rapidly be accomplished?
1. applying direct pressure to the source of bleeding
2. using electrosurgical or tissue-sealing devices
3. clamping and ligating the blood vessels with surtures
4. applying hemostatic agents
224
the RN circulator and anesthesia professional work together during a surgery to carefully monitor when it comes to blood?
the output of blood in suction canisters and the saturation of laparotomy sponges on and off the surgical field
225
why is communication between the RN circulator and anesthesia provider so important when it comes to blood loss?
it is necessary to estimate blood loss accurately and enable both the surgeon and anesthesia provider to make informed decisions regarding fluid replacement
226
the RN circulator should anticipate the need for what for plasma volume expansion?
1. blood products
2. crystalloid (i.e. lactacted ringer solution
3. colloid solutions (i.e. dextran hespan
227
When excessive blood loss occurs what is an alternative or adjunct to donor blood?
autotransfusion (blood salvaging)
228
What kind of risks are associated with autotransfusion?
there are risks of contamination or fat embolism
229
What is the benefit of autotransfusion?
the blood products the patient receives from blood salvaging are the patient's own, so the complications and potential risks (including the costs) associated with donor blood are reduced
230
What is a massive transfusion defined as?
the need for more than 10 units of red blood cells within 24 hours of the start of treatment
231
A mass transfusion protocol is what?
a standard replacement of platelets and clotting factors in an optimum ratio to packed red blood cells
232
what is the goal of a mass transfusion protocol?
increasing speed and efficiency of transfusion
233
Is there a perfect ratio of packed red blood cells, platelets, and FFP?
no there is controversy
234
What 3 other things can be used in autotransfusion but do not have consistent results?
1. cryoprecipitate
2. fibrinogen concentrate
3. recombinant factor VIIa
235
Hand off to the next level of care as far as transfusion should include what?
the amount of blood loss, the replacement products used, and the patient's response to treatment (periop grand rounds), the results of point of care testing
236
What is the purpose of computed tomography?
identifies bone and soft tissue injury
237
What are the areas of interest for CT?
brain, major blood vessels, penetrating wounds
238
What is the purpose of diagnostic peritoneal lavage?
identifies intraabdominal injury
239
What is the area of interest for diagnostic peritoneal lavage?
abdominal organs
240
What is the purpose of focused assessment with sonography (FAST)?
determines presence of free fluid in chest and abdomen
241
What are the areas of interest of FAST?
heart, kidneys, pelvis
242
What is the purpose of ultrasonography?
diagnoses injury to organs
243
What are the areas of interest of ultrasonography?
pelvis, abdomen, bladder, heart
244
What is the purpose of x-ray?
identifies spinal injuries
245
What are the areas of interest of x-ray?
cervical, thoracic, and lumbar spine; pelvis
246
The trauma patient's multisystem injuries require perioperative specific knowledge related to what 3 things?
1. rapid sequence induction to secure and manage the airway
2. autotransfusion to maintain circulating blood volume
3. the potential for organ procurement
247
Why is RSI preferred in trauma situations?
health care providers assume that the patient's stomach is full and that the patient is at high risk for aspiration
248
What are basic principles to reduce the risk of aspiration of stomach contants?
1. pre-oxygenation
2. pretreatment with paralytics
3. positioning to ensure a quick, aspiration free induction
249
a respiratory rate of 10-29 would earn what revised trauma score
4
250
a respiratory rate of >29 would earn what revised trauma score
3
251
a respiratory rate of 6-9 would earn what revised trauma score
2
252
a respiratory rate of 1-5 would earn what revised trauma score
1
253
a respiratory rate of 0 would earn what revised trauma score
0
254
A systolic blood pressure >90 would earn what revised trauma score
4
255
A systolic blood pressure 76-89 would earn what revised trauma score
3
256
A systolic blood pressure 50-75 would earn what revised trauma score
2
257
A systolic blood pressure 1-49 would earn what revised trauma score
1
258
A systolic blood pressure 0 would earn what revised trauma score
0
259
A GCS score of 13-15 would earn what revised trauma score
4
260
A GCS score of 9-12 would earn what revised trauma score
3
261
A GCS score of 6-8 would earn what revised trauma score
2
262
A GCS score of 4-5 would earn what revised trauma score
1
263
A GCS score of 3 would earn what revised trauma score
0
264
What is organ procurement
the process of evaluating and procuring donor organs for transplantation
265
Organ donation may be possible if efforts to do what are unsuccessful?
resuscitate a trauma victim
266
Policies for organ procurement following brain or cardiac death vary among what?
states and facilities
267
the National Organ Transplant Act of 1984 established what?
the Organ procurement and Transplantation Network to improve the matching of donors and recipients
268
Hospitals are required to do what with organ procurement?
to develop policies and procedures to ensure that families are educated about the option to donate
269
What do hospitals risk if they don't develop policies and procedures to ensure that families are educated about the option to donate?
they risk losing medicare and medicaid funding
270
What are the basic steps of RSI?
1. preoxygenate with 100% oxygen
2. induce anesthesia by administering a neuromuscular agent to rapidly achieve loss of consciousness
3. apply cricoid pressure (i.e. Sellick manuever) to help prevent the patient from aspirating stomach contents while inserting the ET tube
4. inflate the endotracheal tube cuff
5. verify endotracheal tube placement
6. secure the ET tube
7. release cricoid pressure only when the anesthesia professional states that it is safe to do so
8. verify ventilator settings
9. monitor the patient according to routine
271
Disaster plans include what 6 things?
1. an up to date contact list and phone tree. Staff should make sure their phones are on and taking calls in the event of an emergency
2. Clear deliniation of roles. Staff should know their assigned location and responsibilities and understand that their tasks may differ from their usual duties
3. Experienced personnel manning the incident command center and making decisions about staff, the facility, patient volume, and allocation of resources (i.e. PPE, supplies, equipment
4. Collaboration and communication between stakeholders, including personnel from trauma, orthopedic, and emergency departments, nursing staff, and ancillary departments (i.e. security, laboratory, radiology, sterile processing, central supply
5. A predetermined TRIAGE plan that prioritizes care. The order of care may be based on degree
6. plan to privde emotional support to caregivers both during and after the event
272
How may a hospital triage patients following a disaster?
critically ill or injured patients who will not survive without immediate intervention; those who will survive without immediate intervention; and those who will not survive even with intervention.
273
Reverse triage involves what?
making room for casualties by discharging patients home or even transferring them to another facility
274
What is the roll of the OR manager in natural disasters?
1. responsible for directing staff as they arrive at the facility
2. scheduling cases based on urgency
3. providing updates to other departments
275
Communication between the incident command center and the perioperative department should provide what?
provide information on the number of patients expected, their anticipated surgical needs, and the severity of their injuries
276
The CDC lists what 4 agents as most likely to be used during bioterrorist attack?
1. bacillus anthracis (anthrax)
2. Clostridium botulinum (botulism)
3. Yersinia pestis (plague)
4. variola virus (smallpox)
277
For all suspected or confirmed cases of bioterrorism what should facilities follow?
follow their disaster plans in addition of standard precautions
278
What are signs and symptoms of bacillus anthracis (anthrax)?
1. respiratory flu-like symptoms
2. itching of head, forearms, or hands
3. abdominal pain
4. nausea
5. vomiting
6. bloody diarrhea
7. toxemia
8. sepsis
279
How is bacillus anthracis transmitted?
1. skin contact
2. ingestion
3. inhalation of spores from infected animals or animal products
4. person-to-person transmission of inhaled diseases does not occur
280
What are infection control practices for bacillus anthracis?
1. standard precautions
2. special cleaning, disinfection, and sterilization of equipment and environment is not needed
281
What are s/sx of clostridium botulinum?
flaccid paralysis
282
What is transmission of clostridium botulinum?
1. ingestion of contaminated food is most common - inhalation is possible
2. person-to-person transmission does not occur
283
What are infection control practices for clostridium botulinum?
1. standard precautions
2. special cleaning, disinfection, and sterilization of equipment and environment is not needed
284
What are the s/sx of yersinia pestis?
1. fever
2. cough
3. chest pain
4. hemoptysis
5. muco-purulent or watery sputum
285
What is transmission of yersinia pestis?
1. airborne (bioterrorism)
2. person-to-person transmission is possible through droplets
286
What are infection control practices for yersinia pestis?
1. standard plus droplet precautions
2. special cleaning, disinfection, and sterilization of equipment and environment is not needed
287
What are s/sx of variola virus?
1. flu-like symptoms
2. skin lesions and rash, most prominent on the face and extremities, progressing to trunk, mouth, and throat
288
What is transmission of variola virus?
1. airborne, droples, and contact with skin lesions/excretions
2. a single case is considered a public health emergency
289
What are infection control practices for variola virus?
1. airborne and standard precautions
2. the patient should be placed in a negative-airflow room (6-12 air exchanges per hour, door closed)
3. follow contact precautions when cleaning potentially contaminated surfaces/equipment
290
What is the best assurance of positive outcomes with an active shooter?
prep and planning before the event by a multidisciplinary team is the best
291
What is an active shooter
a person attempting to kill or killing people in a populated area
292
What puts the OR department at risk for active shooters?
1. isolated staff working during off shifts
2. the potential for drug-related robbery
3. emotional visitors and family members put the department at risk
293
What should response plans of an active shooter include?
1. early reporting of suspicious or threatening behavior, whether in person or via social media
2. lockdown, evacuation, and escape procedures
3. accounting for employees and patients during an event
4. adapting to loss of services
294
the response to an active shooter is based on what 3 premises?
1. run
2. hide
3. fight
295
What does running entail with an active shooter?
1. staff and patients can leave the deparment and reach a safe environment.
296
What should be avoided with active shooters?
elevators
297
Because escape may not be feasible with anesthetized or otherwise mobility-impaired patient, staff may need to what?
HIDE; staff may shelter in locked areas or barricade themselves and their patients in operating rooms
298
Personnel who are in the immediate vicinity of an active shooter and cannot run or hide may do what?
choose to aggressively confront the person with distraction or force
299
What does the landmark document published by the ANA in response the COVID-19 pandemic detail?
nurses are reminded that they have a duty to provide care during a crisis and that employers have a corresponding duty to provide as safe a practice environment as possible
300
any decision to move t a crisis standard of are requires what?
input from a multidisciplinary team of health care professionals and community leaders
301
